Clinical Case Summary

A 53-year-old woman was diagnosed with a severe eosinophilic esophagitis showing poor response to multiple therapies, such as high dose of proton pump inhibitors, oral, topical (swallowed fluticasone) and systemic steroids. She was paucisintomatic for reflux disease or dysphagia.
She had history of multiple immune diseases, including Sjogren syndome, autoimmune gastritis, HCV related hepatitis treated with DAA, Hashimoto's thyroiditis, cutaneus and oral lichen planus and multiple allergies.
After 4 years of follow up histopatological findings shifted to a lichenoid esophagitis pattern and all the following endoscopies confirmed the diagnosis of lichen planus esophagitis (LPE).
Endoscopic examinations of the esophagus revealed lacy white papules, rings, desquamation and high bleeding tendency leading to a difficult mucosal evaluation and accurate biopsy sampling.
This condition was refractory to the treatment mentioned above and evolved in stenosing esophagitis (off therapy) associated with solid food dysphagia.
She was then treated with high dose of oral viscous budesonide showing a remission of the stricture with a persistence of endoscopical and histopatological acute inflammatory activity.
Treatment was shifted to Budesonide orodispersible tablets (BOT), showing a dramatic improvement of endoscopical appearance and bleeding tendency, allowing an accurate sampling with a complete histologycal response of LEP after an year of therapy (1 mg BD for 6 months then 0.5 mg BD for 6 months).
After reducing BOT doses to 0.5 mg once daily for 6 month endoscopy showed a recurrence of LEP.
Lichen planus is a subacute to chronic inflammatory disease. Esophageal involvement (LPE) is frequently an underrecognized condition but bears important therapeutic implications, due to its chronic and relapsing tendency, and may have malignant potential[1].
Endoscopy and tailored long term therapy remain crucial. We suggest BOT as a viable treatment option for LPE.

References

Image captions:
1) Endoscopic appearence of acute lichen planus esophagitis (LPE)
2) Stenosing LPE
3) Lichenoid histologic appearence of esophageal mucosa
4) Post treatment esophageal mucosa appearence
5) Post treatment histologic appearence of esophageal mucosa
References: [1] Annegrit Decker et Al "Esophageal lichen planus: Current knowledge, challenges and future perspectives" World J Gastroenterol. 2022 Nov 7;28(41):5893–5909. doi: 10.3748/wjg.v28.i41.5893

Introduction

The primary treatment goals of gastroesophageal reflux disease (GERD) include resolving symptoms, preventing complications and symptom relapses, and healing erosive oesophagitis.^{1, 2} Heartburn and regurgitation are frequent and typical symptoms of GERD. Vonoprazan, a potassium-competitive acid blocker, is approved in China for the treatment of reflux oesophagitis.^{3, 4} However, there is a paucity of real-world data assessing the relief of typical daily symptoms achieved with vonoprazan in adult Chinese patients.

Aims & Methods

VIEW (NCT04501627) was a multicentre, single-arm, prospective, observational, real-world study conducted in China. Patients received 20 mg vonoprazan, orally, once daily for 4 weeks (8 weeks for insufficient healing). This post hoc subgroup analysis conducted in enrolled patients with GERD assessed changes in symptom scores for all-day or night-time heartburn and/or regurgitation during the first 14 days of treatment. A mixed-effects model for repeated measures assessed statistical differences in symptom scores from baseline for each day; least-squares mean (LSM) and its 95% confidence interval are reported (negative values indicate improvement).

Results

Among the 2214 patients included in the effectiveness analysis population of the GERD group, 86.7% were aged <65 years[A.G.1] and 60.8% were male. The LSM change in symptom scores from baseline demonstrated a significant improvement from day 1 of treatment in all-day heartburn and/or regurgitation, daytime heartburn or regurgitation, and night‑time heartburn or regurgitation (Table). Significant improvement continued to be observed on day 14 and throughout all previous days of treatment.

Conclusion

Vonoprazan provided rapid (from day 1), significant and durable symptom relief in patients with GERD.

Table: Improvement in symptom scores^a from baseline to day 14 of vonoprazan treatment (effectiveness analysis population; MMRM analysis)

References

1. Antunes C, Aleem A and Curtis SA. StatPearls. Treasure Island (FL), 2023.
2. Heidelbaugh JJ, Nostrant TT, Kim C, et al. Am Fam Physician 2003; 68: 1311-1318.
3. Xiao Y, Lu Y, Yang H, et al. Am J Gastroenterol 2023; 118: S345-S345.
4. Oshima T and Miwa H. J Neurogastroenterol Motil 2018; 24: 334-344.

Disclosure

This study was funded by Takeda (China) International Trading Co. Ltd. Yinglian Xiao, Dekui Zhang and Jianyong Chen have no conflicts of interest. Kailun Liang and Li Xie are Takeda employees and hold Takeda stock options. Minhu Chen received speaker honoraria from Takeda China, AstraZeneca China, Xian Janssen and Eisai China.

Introduction

Aging is associated with physiological changes in esophageal function, influencing motility and increasing susceptibility to dysphagia.

Aims & Methods

This study investigates esophageal peristaltic reserve across different age groups by employing multiple rapid swallow (MRS) during high-resolution manometry (HRM). A retrospective analysis was conducted on 331 patients presenting with dysphagia who underwent HRM between 2021 and 2023. Participants were stratified into four age groups: early adulthood (≤34 years, 12.1%), early middle-age (35–49 years, 12.7%), late middle-age (50–64 years, 45.3%), and late adulthood (≥65 years, 29.9%). Peristaltic reserve was assessed using MRS to evaluate esophageal contractile function.

Results

Among the 311 patients included, 195 (58.9%) were male, with a median age of 57 years (IQR 45–66). The prevalence of normal esophageal motility was highest in early adulthood (67.5%) and early middle-age (78.6%) but declined significantly in late middle-age (48.7%; p=0.014) and late adulthood (44.4%; p<0.001). Late adulthood was also characterized by lower median upper esophageal sphincter (UES) pressure (101 mmHg) and reduced UES length (3 cm; p<0.05). Additionally, esophagogastric junction (EGJ) type II and III morphology was more frequently observed in late adulthood (52.5%; p<0.05). In patients with normal motility (n=177), MRS motor wave transmission was lower in late adulthood (75%, p<0.05) compared to early adulthood (96.3%), early middle age (88.1%) and late middle age (93.2%), and the prevalence of incomplete MRS inhibition was higher in late adulthood (79.5%, p<0.05) compared to early adulthood (11.1%), early middle age (21.2%) and late middle age (46.6%). The DCI-MRS and DCI wet ratio were significantly lower in late adulthood (0.51, IQR 0.13 – 0.88; p<0.01).

Conclusion

Peristaltic reserve declines with advancing age, which may contribute to dysphagia. MRS proves to be a useful diagnostic tool for detecting subtle motility impairments related to aging.

Introduction

Guidelines recommend independent auditing of diagnostic performance for clinical implementation of computer-aided optical polyp diagnosis (CADx).

Aims & Methods

This study aimed to evaluate diagnostic performance and interobserver agreement of auditors, and to offer guidance on conducting CADx audits. Images and videos of all ≤5-mm polyps from a large prospective study with systematic activation of CADx were audited by three expert endoscopists. Experts performed independent, blinded diagnostic review including documentation of confidence level. The primary outcome was sensitivity of audit by three experts for high-confidence adenomas compared with pathology. Secondary outcomes included the number of reviewers for optimal CADx auditing and interobserver agreement.

Results

487 diminutive polyps were audited (510 patients). Sensitivity was 99.4% (95%CI 96.0–100) using three experts (Strategy A); 88.7% (95%CI 84.1–92.1) using two experts and one referee (Strategy B); 99% (95%CI 96–99.8), 98.8% (95%CI 95.4–99.8), and 99.4% (95%CI 96.3–100) using two-expert combinations (Strategy C); and 98.2% (95% CI 95.1-99.4), 97.3% (95% CI 94.0-98.9), and 88.9% (95% CI 83.6-92.7) for each expert individually (Strategy D). Among 266 pathology-based adenomas, Strategy A evaluated 160 polyps versus 196, 172, and 170 in Strategy C; and 220, 223, and 207 in Strategy D. Strategy B evaluated all 266 adenomas. Overall interobserver agreement was moderate (kappa 0.52), but very high for high-confidence adenomas (kappa 0.89).

Conclusion

Expert audit for evaluating CADx resulted in high sensitivity and interobserver agreement for high-confidence adenomas. Audit by two experts, with a third expert for arbitration, permitted audit of all polyps and could effectively assess CADx within clinical studies.

Disclosure

Daniel von Renteln has received research funding from ERBE Elektromedizin GmbH, Ventage, Pendopharm, Satisfai, Fujifilm, and Pentax, and has received consultant or speaker fees from Boston Scientific Inc., ERBE Elektromedizin GmbH, Medtronic, and Pendopharm. Roupen Djinbachian has received speaker fees from Fujifilm. The remaining authors declare that they have no conflict of interest.

Introduction

The diagnosis of small bowel motility disorders currently relies on identifying abnormal contractile patterns through intestinal manometry, but the technique is restricted to referral centers. Conventional CT scanning, frequently performed in the routine evaluation of these patients, provides images of intestinal content, which might serve as a marker of intestinal dysfunction. We hypothesized that pooling of intestinal content, quantified through computerized analysis of abdominal CT images, could serve as an indirect marker of small intestinal motor dysfunction.

Aims & Methods

Consecutive patients with either a) chronic intestinal pseudo-obstruction (CIPO) or b) suspected small intestinal motor dysfunction, evaluated at our Motility Unit using high-resolution jejunal manometry, were prospectively included. Manometric tracings were categorized as
a) normal,
b) uncoordinated contractile activity with preserved amplitude, or
c) hypomotility (markedly diminished amplitude of contractile activity).
All patients also underwent an abdominal CT scan within three months of the manometric study, as part of the clinical evaluation of the motility disorder. CT images were analyzed using a validated software developed in our laboratory, which applies image processing techniques and deep-learning tools to identify and quantify intestinal content volumes in the small bowel and colon of:
a) gas,
b) chyme-type content (non-gaseous, homogeneous texture), and
c) fecal-type content (non-gaseous, heterogeneous texture).

Results

Of the 66 patients included, 9 had CIPO and 57 suspected dysmotility. Manometry was abnormal in all patients with CIPO and in 22 patients (39%) without CIPO. Total intestinal content was markedly increased in patients with CIPO as compared with patients with normal motility (3034±826 mL vs 398±43 mL, respectively; p<0.001), primarily due to an increase in gas (1086±325 mL vs 22±4; p<0.001) and chyme-type content in the small bowel (1282±544 mL vs 81±11; p<0.001).
Among patients without CIPO, the volume of small bowel content was increased in patients with dysmotility compared to those with normal motility, mainly of chyme-type content (191±39 vs 81±11 mL in normal motility; p=0.006). Colonic volumes of gas and fecal-type content were also higher in patients with dysmotility than in those with normal motility (gas 224±40 vs 115±18 mL, p=0.027; fecal-type 244±59 vs 115±19 mL, p=0.036). Dysmotility patients with hypomotility patterns had overall higher intestinal content volumes than patients with uncoordinated contractile patterns (Table 1).

Table 1. Intestinal content volumes in non-CIPO patients, classified by manometric patterns

Conclusion

Intestinal content, measured on conventional CT scans by a specific analysis program, provides a useful indication of intestinal dysmotility.

Introduction

While anatomical landmark identification and adequate inspection time are recognized as crucial quality indicators in upper endoscopy, they are difficult to document consistently and accurately based solely on endoscopist reports.

Aims & Methods

To address this issue at Assuta Healthcare, a multicenter organization with 20 endoscopy units and over 200 endoscopists, we implemented a video-based AI platform designed to measure total upper endoscopy time (EGD-T), assess photo documentation of landmarks, and streamline the photo labeling process. In the current study, we evaluated the platform and employed it to examine endoscopist-reported quality measures.
For all upper endoscopies performed at Assuta Healthcare in 2024 on patients 45 years and older, the Theator AI-based Surgical Intelligence platform automatically documented total procedure time as well as photo snapshots captured and labeled by endoscopists for seven landmarks: 1. esophagus, 2. gastroesophageal junction, 3. cardia or fundus, 4. body, 5. angulus, 6. antrum or pylorus, and 7. duodenum (second part). In a subset of procedures, the platform facilitated documentation by suggesting labels for captured snapshots. After validating platform accuracy, we examined platform-reported procedure times. We then assessed landmark photo documentation rates in procedures with and without platform labeling suggestions.

Results

The study included 21,989 upper endoscopies (60.7% female, median age of 62.2 years), of which 51.7% were conducted with platform labeling suggestions and the remaining 48.3% were conducted without. Validated platform accuracy was 98%. Median total procedure time measured by the platform was 3.18 minutes (IQR 2.18-4.25). When they did not receive suggestions, endoscopists did not label any landmarks in 25% of procedures. At 12%, this percentage was significantly lower (p < .001) when the platform did provided suggestions. This difference was also reflected in the median number of landmarks labeled, which was 2 (IQR 0-3) in procedures without labeling suggestions and 3 (IQR 1-4) in procedures with labeling suggestions (p < .001).

Conclusion

Implementing an AI tool to automatically assess procedure time in upper endoscopy provided accurate measurements, revealing durations considerably lower than recommended. It further revealed extremely low labeling rates, which increased when automated suggestions were provided. The results highlight critical gaps in the reporting of quality measures for upper endoscopy and indicate that AI-based documentation can be instrumental to quality assurance by identifying and addressing such gaps.

Disclosure

None

Introduction

Intraoperative hypotension (IOH) during endoscopic procedures under general anesthesia is associated with adverse outcomes, including prolonged recovery and increased postoperative complications. However, its clinical impact remains underexplored (Sessler & Saugel, 2019). This study assesses the incidence, risk factors, and consequences of IOH in patients undergoing endoscopic procedures.

Aims & Methods

A prospective observational study was conducted on 1,100 patients undergoing various endoscopic procedures under general anesthesia over 12 months. Continuous hemodynamic monitoring was performed, and IOH was defined as a systolic blood pressure <90 mmHg or a ≥20% reduction from baseline (Bijker et al., 2009). Patient demographics, comorbidities, procedure duration, and clinical outcomes were analyzed. Multivariate regression identified independent risk factors and their association with postoperative complications, unplanned admissions, and recovery time.

Results

IOH occurred in 9.5% of patients and was significantly associated with age ≥40 years (p < 0.05), pre-existing hypertension (p < 0.01), and procedure duration >60 minutes (p < 0.05). Patients with IOH had prolonged recovery times (+45 minutes, p < 0.05), higher postoperative complications (21% vs. 9%, p < 0.01), and increased unplanned hospital admissions (15% vs. 5%, p < 0.01) (Smischney et al., 2015).

Conclusion

Intraoperative hypotension significantly affects patient outcomes, leading to prolonged recovery and increased postoperative morbidity. Early identification and hemodynamic optimization may reduce these risks, improving procedural safety and patient recovery (Brady et al., 2014).

References

1. Sessler DI, Saugel B. Beyond ‘systolic blood pressure’. Anesthesiology. 2019; 131(3):738-740.
2. Bijker JB, Persoon S, Peelen LM, et al. Intraoperative hypotension and 1-year mortality after noncardiac surgery. Anesthesiology. 2009; 111(6):1217-1226.
3. Smischney NJ, Pour-Ghaz I, Kaczmarek HE, et al. Intraoperative hypotension and risk of critical care admission after noncardiac surgery. Anesthesiology. 2015; 123(1):85-95.
4. Brady KM, Rhee CJ, Smielewski P, et al. Poor autoregulation and morbidity in pediatric traumatic brain injury. Pediatr Crit Care Med. 2014; 15(7):636-645.