Introduction

Risk stratification is vital in upper gastrointestinal bleeding (UGIB) to guide management decisions. Several risk scores to predict adverse outcomes of UGIB have been developed, however, real-world comparisons across diverse patient outcomes are limited. We aimed to validate and compare the discriminatory performance of five established UGIB risk scores for inpatient mortality, including subgroup analysis for variceal and non-variceal bleeding aetiologies.

Aims & Methods

We retrospectively analysed 1,003 patients who received inpatient esophagogastroduodenoscopy (OGD) on admission between January 2025 and August 2023 at a tertiary centre. Each patient’s ABC, CHAMPS, MAP(ASH), Glasgow-Blatchford (GBS), and Japanese scores were calculated. The outcome measured was 30-day inpatient mortality. Receiver operating characteristic (ROC) and area under the curve (AUC) were calculated to assess each score’s discriminative ability. Further subgroup analyses were performed depending on the aetiology of UGIB (variceal vs non-variceal).

Results

Between the five analysed scores, the ABC score (AUC: 0.817) had the highest overall prediction ability for 30-day inpatient mortality, followed by CHAMPS (AUC: 0.791) and MAP(ASH) (AUC: 0.774). GBS and the Japanese scores demonstrated moderate to poor accuracy (AUC: 0.713 and 0.614, respectively). A similar pattern was displayed for variceal UGIB subgroup, with the ABC score being the best performing (AUC: 0.826), followed by CHAMPS (AUC: 0.774). MAP(ASH), GBS, and the Japanese score had poor predictive values (AUCs: 0.694, 0.660, and 0.540, respectively). ABC, CHAMPs, and MAP(ASH) demonstrated strong predictive accuracy in the non-variceal UGIB subgroup, with AUCs: 0.818, 0.792, and 0.787, respectively. Whilst GBS (AUC = 0.728) and the Japanese score (AUC = 0.627) had less reliability.

Conclusion

In this real-world UK cohort, the ABC score outperformed four other established scoring systems in predicting inpatient mortality in UGIB. Thus, our findings may indicate ABC score to be the most dependable score for early risk assessment in acute UGIB patients, independent of bleeding aetiology, followed by CHAMPS and MAP(ASH).

Introduction

Endoscopy services in many healthcare systems face increasing demand, and novel approaches to patient triage are needed. Recent research suggests that capsule sponge testing combined with immunohistochemical biomarkers can prioritise patients with Barrett’s oesophagus (BO) and gastro-oesophageal reflux for oesophagogastroduodenoscopy (OGD).^1,2 However, it is not yet widely integrated into clinical practice globally. The capsule sponge is not currently used in South Wales and Northern Ireland, and further investigation into its implementation in these regions is required.

Aims & Methods

This multicentre feasibility study aimed to evaluate whether the capsule sponge could be used in Wales and Northern Ireland to triage patients with gastro-oesophageal reflux or BO for OGD, and to assess feedback from patients and staff. Patients referred to gastroenterology due to gastro-oesophageal reflux and patients with known BO under surveillance were eligible. Patients were recruited from 3 hospital sites in Wales and 2 in Northern Ireland, undergoing the test in nurse-led clinics between December 2024 and March 2025. Pathology samples were processed centrally in an accredited laboratory (Cyted), examining for TFF3 (suggestive of intestinal metaplasia), p53 and atypia (high-risk findings associated with dysplasia). Patient feedback was collected at the clinics, and feedback forms were also sent to patients and staff.

Results

201 patients were recruited, with 196 (97.5%) completing the capsule sponge test: 116 with BO (median age 59, 84% male) and 80 with reflux (median age 49, 56% female). 101 BO samples (87%) were adequate for analysis. Of these, 21 (21%) were positive/equivocal for atypia/p53 and deemed high-risk, and 80 (79%) were negative for both atypia and p53. High-risk patients were prioritised for urgent OGD, with the remainder followed-up as per the British Society of Gastroenterology guidelines. 61 samples (76%) from patients with reflux were adequate for analysis. Of these, 3 (5%) were positive/equivocal for atypia/p53 and prioritised for urgent OGD, 11 (18%) were TFF3 positive but negative for both atypia and p53 and were booked for routine OGD, and 47 (77%) were negative for all 3 biomarkers and were managed as per usual local practice.
148 patients (76%) who completed a capsule sponge test had previously had an OGD, with 78% of these preferring the capsule sponge, 4% preferring the OGD and 9% being unsure. Feedback forms were completed by 52 patients, with response rates varying by question. 92% rated the capsule sponge procedure good/very good, 3% fair and 5% poor/very poor. When asked how likely they would be to recommend the test, on a scale from 1 (least likely) to 10, patients with reflux gave a mean score of 8.7 and patients with BO 9.6. For whether they would be willing to have the test done again, 83% said yes, 14% not sure and 3% no. Patients’ free text comments indicated they found the capsule sponge to be quicker and easier than an OGD, however some experienced discomfort on sponge withdrawal. 14 staff completed feedback forms. 100% agreed the capsule sponge test was easy to deliver, and 100% rated the implementation of the test pathway as good/very good.

Conclusion

This feasibility study showed that the capsule sponge could successfully triage patients under BO surveillance or with reflux for OGD in Wales and Northern Ireland, with positive feedback from patients and staff. These findings support future integration of the capsule sponge into clinical pathways in these regions, with potential transferability to other healthcare systems internationally.

References

1. Chien S, Glen P, Penman I, Cruickshank N, Bryce G, Crumley A, et al. Oesophageal cell collection device and biomarker testing to identify high-risk Barrett’s patients requiring endoscopic investigation. Br J Surg. 2024 May 13;111(5):znae117.
2. Chien S, Glen P, Bryce G, Cruickshank N, Penman I, Robertson K, et al. Clinical application of capsule sponge testing in symptomatic reflux disease: a national prospective cohort study. BMC Gastroenterol. 2024 Nov 26;24:431.

Disclosure

R McNally, B Afinowi, I Aldred and R Hardwick are employed by Cyted Health, who manufacture the capsule sponge device used in this study. The remaining authors have nothing to disclose.

Introduction

Endoscopic submucosal dissection (ESD) is a widely performed and minimally invasive treatment for superficial oesophageal cancer, offering a less invasive alternative to surgical resection. However, when pathological findings indicate non-curative resection, additional treatment becomes necessary.

Aims & Methods

This study aims to evaluate the clinical outcomes of chemotherapy in high-risk cases of oesophageal cancer following ESD. Among 761 patients who underwent oesophageal ESD at our institution between June 2006 and August 2023, 49 cases with squamous cell carcinoma or basaloid carcinoma, classified as pT1a-MM with lymphovascular invasion or pT1b-SM, were selected. These were divided into two groups: 16 patients who received additional chemotherapy (Group A) and 15 patients who underwent chemoradiotherapy (Group B). Group A was treated with 5-fluorouracil (5-FU) with or without cisplatin (CDDP), while Group B received a combination of 5-FU, CDDP, and radiotherapy.

Results

There were no significant differences in patient demographics, tumour characteristics, or pathological factors between the groups. The median age was 69 years in both groups, with 14 males in Group A and 12 in Group B. All patients had a performance status of 0–1. The Charlson Comorbidity Index scores (0/1/2–) were 9/5/2 in Group A and 6/7/2 in Group B. Tumour location (Ut/Mt/Lt) was 2/6/8 in Group A and 1/7/7 in Group B. The median tumour length was 26 mm in Group A and 24 mm in Group B. Tumour circumference of two-thirds or less was observed in 15 patients in Group A and 13 in Group B.
In terms of depth of invasion (MM/SM1/SM2), the distribution was 5/4/7 in Group A and 3/2/10 in Group B. Lymphovascular invasion (ly+/v+) was observed in 7/2 cases in Group A and 4/4 in Group B. Horizontal margin status (negative/positive/indeterminate) was 15/1/0 in Group A and 12/1/2 in Group B, while vertical margin status was 14/1/1 in Group A and 11/3/1 in Group B. Histologically, all cases in Group A were squamous cell carcinoma, while Group B included 14 squamous cell carcinoma and 1 basaloid carcinoma.
The median follow-up period was 6.79 years in Group A and 2.79 years in Group B. The five-year overall survival rate was significantly higher in Group A (100.0%) compared to Group B (77.7%; p<0.001, log-rank test). The five-year relapse-free survival rate was also significantly better in Group A (92.3%) than in Group B (84.8%; p=0.008). In Group B, there was one death due to the primary disease and four deaths from other causes. Both groups reported one case of lymph node recurrence.
The median length of hospital stay was significantly shorter in Group A (34 days) than in Group B (48 days; p<0.001). Grade 3 or higher adverse events occurred in 4 patients in Group A and 11 in Group B (p=0.012), indicating significantly higher toxicity in the chemoradiotherapy group.

Conclusion

These findings suggest that chemotherapy may serve as a viable option for additional treatment following non-curative ESD in high-risk oesophageal cancer cases. Chemotherapy was associated with favourable survival outcomes, fewer adverse events, and shorter hospitalisation compared to chemoradiotherapy.

Introduction

Opportunistic screening is one major screening approach for esophageal squamous cell carcinoma (ESCC). Risk stratification models could be used to assess each individual's risk using relevant predictors so that only those at high risk are recommended for further endoscopy ^1-2. This approach would allow the development of a cost-effective opportunistic screening strategy and promise to improve the sensitivity of endoscopic detection by alerting the endoscopists.

Aims & Methods

We aimed to develop a score-based clinical prediction model to assess the risk of ESCC and precancerous lesions in opportunistic screening and to validate it in an external population. The study was a secondary analysis of a published esophageal cancer screening trial ³. The trial was conducted in 39 secondary or tertiary hospitals in China, with 14,597 individuals enrolled for opportunistic screening. Additionally, questionnaires and endoscopy were performed. The primary outcome was histology-confirmed high-grade esophageal lesions, including high-grade intraepithelial neoplasia (HGIN) and ESCC. The predictors were selected using univariable and multivariable logistic regression. Model performance was primarily measured with the area under the receiver operating characteristic curve (AUROC).

Results

The score-based prediction model contained 8 variables on a 21-point scale. The model demonstrated an AUROC of 0.833 (95% CI, 0.803-0.862) and 0.828 (95% CI, 0.793-0.864) for detecting high-grade lesions in the development and validation cohorts, respectively. As shown in Table 1, using the score cut-off value determined in the development cohort (≥9), the sensitivity reached 70.0% (95% CI, 50.6%-85.3%), 81.3% (95% CI, 63.6%-92.8%), and 81.1% (95% CI, 64.9%-92.0%) in the validation cohort for detecting HGIN, early ESCC, and advanced ESCC, respectively, at a specificity of 76.4% (95%CI,75.4%-77.4%). The score-based model exhibited satisfactory calibration in the calibration plots. The score-based model could result in 75.6% fewer individuals subjected to endoscopies.

Conclusion

This score-based model demonstrated superior discrimination for high-grade esophageal lesions. It has the potential to inform referral decisions in the opportunistic screening setting.

References

1. Jiang H, et al. Performance of Prediction Models for Esophageal Squamous Cell Carcinoma in General Population: A Systematic Review and External Validation Study. Am J Gastroenterol 2024;119:814–22.
2. Zheng H, et al. Development and external validation of a quantitative diagnostic model for malignant gastric lesions in clinical opportunistic screening: A multicenter real-world study. Chin Med J (Engl) 2024;137:2343–50.
3. Gao Y, et al. Machine learning-based automated sponge cytology for screening of oesophageal squamous cell carcinoma and adenocarcinoma of the oesophagogastric junction: a nationwide, multicohort, prospective study. The Lancet Gastroenterology & Hepatology 2023;8:432–45.

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

The treatment of esophageal motor disorders (EMD) has historically been focused on decreasing pressure at the gastro-esophageal junction (GEJ) by disrupting muscular fibers at this level. The classic management through dilatation, botulinum toxin injection, and Heller's myotomy (HM) underwent a revolution with the advent of third-space endoscopy, offering safe access to the submucosal space and enabling peroral endoscopic myotomy (POEM).
In this prospective national multicenter study, the results of the implementation period of this technique in Spain from 2016 to the present are analyzed, examining its short, medium, and long-term outcomes. Furthermore, outcomes based on EMD, previous treatments, and other multiple variables are also investigated.

Aims & Methods

The primary aim of this study was to ascertain the clinical efficacy of POEM.
Secondary objectives included the identification of predictors of clinical success and the measurement of the incidence of post-POEM GERD and significant complications, as well as the determination of the risk factors for complications
This is a prospective multicenter study conducted across 13 hospitals in Spain. Symptomatic patients undergoing POEM for any EMD were recruited between June 2016 and February 2023. Baseline characteristics, procedural details and outcomes related to efficacy and safety during short and long-term follow-up were analyzed.

Results

A total of 441 patients were enrolled, with type II achalasia representing the most common diagnosis (62.1%). POEM was the primary treatment in 277 patients (62.8%). Clinical success data were available for 396 patients, with a success rate of 94.4% at the last available follow-up (2 years in 117 patients, 1 year in 140, <1 year in 139). A higher baseline Eckardt score was an independent risk factor for clinical failure in the long-term follow-up (p = 0.024). Symptomatic reflux occurred in 4.7% of the patients, with a significant esophagitis rate of 10.1%. Complication incidence was 9.3% (41/441), including 14 (3.2%) severe events. Older age (p = 0.025) and total procedure duration (p=0.036) were independent risk factors for complications, while mucosal injury was found to be a predictor of severe complications (p = 0.027).

Conclusion

These findings confirm the clinical efficacy and safety during the implementation phase of POEM for all EMD in Spain.

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.