Introduction

Inflammatory bowel disease (IBD) is associated with a 2-3-fold risk of venous thromboembolic complications. This risk is further increased by disease flare. However, there is a lack of studies systematically searching for these events and identifying other risk factors in IBD patients.

Aims & Methods

The aim of a prospective cohort study was to evaluate the occurrence of perfusion disorders in the pulmonary circulation in patients with acute severe ulcerative colitis (ASUC). A cohort of patients from a single tertiary IBD centre hospitalized with an episode of ASUC was recruited from January 2023 to April 2025. Ventilation-perfusion (V/P) SPECT was performed in all patients after hospital discharge. In case of detection of primary perfusion defect, anticoagulation treatment was initiated in patients not yet anticoagulated.

Results

Fifty four patients with relapse of UC requiring hospital stay due to disease activity in the past 24 months in whom V/P SPECT was performed were identified. None of the patients had clinical symptoms of pulmonary embolism. Mean age of the cohort was 37.0±13.4 years (min-max 19-76 years). Of them 53.7% (29/54) were males. Mean disease duration at the time of V/P SPECT was 7.1±7.1 years (1-35 years). Disease extension included 25.9% patients with left-sided colitis and 74.1% with pancolitis. Active smoking was present in 13.0% of patients and history of using JAK inhibitors was positive in 63.0% of patients. Mean time elapsed between last hospital stay due to UC activity and V/P SPECT was 239.6±216.4 days (12-745). Presence of a perfusion defect was found in 16.7% (9/54) of patients. There were no significant differences in baseline patient and disease characteristics including smoking and JAKi history between positive and negative group. None of the positive patients had previous history of known thrombotic event.

Conclusion

We have identified 16.7% of patients with severe UC relapse in the past 2 years to have signs of perfusion defect on V/P SPECT warranting further research to identify potential risk factors and probability of developing perfusion disorders of pulmonary circulation in patients with ASUC.

Disclosure

Eli Lilly

Clinical Case Summary

A 66-year-old female with a history of prior stroke presented with generalized weakness. She was disoriented and unable to provide a reliable history. She was febrile and tachycardic, and labs were notable for elevated direct bilirubin and liver enzymes. Physical exam was notable for right upper quadrant tenderness and well-healed scarring consistent with prior abdominal surgery. CT abdomen showed intrahepatic micro-abscesses and MRI revealed a cystic duct–duodenal fistula. Due to the patient’s clinical improvement with antibiotics, she was able to be discharged with a plan for outpatient ERCP. Due to issues with insurance coverage following discharge, the patient was lost to follow-up.
This is a rare presentation of a cysto-duodenal fistula that was the source of cholangitis and hepatic micro-abscesses resulting in sepsis. The incidence of cysto-duodenal fistulas is unknown, though fewer than 12 case reports of cystic duct-enteric fistulas have been published. The formation of a fistula can occur after cholecystectomy, involving a persistent cystic duct remnant that can become obstructed by calculi, leading to increased pressure and subsequent fistulization. It can present within days to years following cholecystectomy. This patient’s surgical history was unclear due to her altered mental status and a lack of records, though she had abdominal scarring and imaging findings that were consistent with prior cholecystectomy. It was confirmed that the patient did not have any recent abdominal procedure or cholecystectomy, making her presentation even rarer. Patients with a cysto-duodenal fistula typically present with signs of biliary sepsis, like in this case. ERCP is both a key diagnostic and therapeutic tool, as management of the fistula may involve interventions such as sphincterotomy and stenting to relieve obstruction. If endoscopic management is unsuccessful or if symptoms recur, surgical intervention may be necessary.

References

CT abdomen showed multiple small irregular hypodense lesions concerning for intrahepatic micro-abscesses. MRI was performed for further characterization and revealed inflammatory changes of the cystic duct stump with high suspicion for cystic duct–duodenal fistula and hepatic micro-abscesses (most notable in segment VII) with no drainable abscess.

Introduction

The LiverRisk score was recently developed as a tool for predicting liver fibrosis and liver-related outcomes in the general population. We aimed to evaluate the predictive performance of the LiverRisk score for liver fibrosis and overall mortality in HCV patients treated with direct acting antivirals.

Aims & Methods

This was retrospective, descriptive and analytical study conducted in a gastroenterology department over 8 years including patients diagnosed with chronic hepatitis C. Data were collected from patient records and during their follow-up. The data normality test for this study was conducted using the Shapiro-Wilk test. The discrimination ability of the Liver Risk Score was evaluated using the Area Under the Receiver Operating Characteristic (AUROC) curve. Overall mortality was assessed at the conclusion of the follow-up period.

Results

Among 165 patients monitored for hepatitis C and treated with direct-acting antivirals, only 68(41.2%) patients were eligible for this study. Mean age at diagnosis was 61±13.2 year; sex ratio M/W was 0.78 .10(14.7%) of the patients were tobacco users. 22(32.4%) had hypertension, and 14(20.5%) had diabetes.
Regarding hepatic risk factors; 5(7.5%) had alcohol use disorder, and use of cannabinoid substances was reported in 5(3%) of the cases.1(1.4%) had history of drug injection. 7(10.6%) had a history of bloodletting and tattoos, and 4(6%) had high-risk sexual practices.
Regarding the circumstances of diagnosis, 23(39.7%) patients were diagnosed incidentally, 18(26.4%) following an evaluation for asthenia, 4(6.9%) presented with abdominal pain, and 3(4.4%) exhibited signs of portal hypertension.
In terms of laboratory findings, 25(36.7%) had cytolysis, 7(10.2%) showed biochemical cholestasis, 16(23.52%) had thrombocytopenia, and 5(7.3%) presented with sign of hepatocellular insufficiency. Hepatitis B coinfection was identified in 3(4.4%) cases.
The most frequent genotype was 1b, identified in 18(45%) patients, followed by genotype 2 in 17(25%). Genotypes 1a, 3, and 4 were observed in 5(7.3%) patients.
On ultrasound, 15(22%) patients showed signs of chronic liver disease, and 8(11.7%) exhibited signs of portal hypertension. A total of 26(38.2%) patients underwent upper endoscopy, among whom 13(19.11%) had esophageal varices, 2(2.9%) had gastric or gastroesophageal varices (GOV), and 9(13.2%) presented with hypertensive gastropathy.
46(75.4%) were treated with Sofosbuvir and Daclatasvir, followed by Sofosvubir and Velpatasvir for 9(14.8%). Sustained virological response was achieved for 51(91.1%) patients.
For fibrosis, 19(30.2%%) were at stage F4, 9(14.3%) at stage F3, 13(20.6%) at stage F2, and 22(34.9%) at stage F0-F1. Median Liver risk score was 7.58[6.28;8.5].
The LiverRisk Score exhibited high accuracy in predicting liver stiffness and outperformed traditional serum biomarkers of fibrosis. Its discriminatory capacity for detecting liver stiffness ≥10 kPa was reflected by an AUROC of 0.848, compared to 0.779 for the FIB-4 test. After 5 years follow up 8(11.76%) patients died. LiverRisk score was associated with the risk of all cause of mortality (HR= 1.34, 95% IC[0.98;1.83], p = 0.047).

Conclusion

The LiverRisk score is an accurate tool to predict liver fibrosis and mortality in HCV patients treated with direct acting antivirals.

Introduction

The Chicago Classification version 4.0©(CC4) provided an updated classification of oesophageal motility disorders based on high-resolution oesophageal manometry (HRM) findings[1-2]. A key modification included using solid swallows which have been shown to increase the diagnostic yield of oesophageal motility disorders[3]. CC4 fails to offer guidance on the weighting of relevant findings when wet and solid swallows are discordant[3]. Clinical judgement, such as incorporating patient reported symptoms, is therefore required when interpreting HRM findings[2-3].

Aims & Methods

This retrospective service evaluation aimed to determine the frequency of CC4 diagnostic discordance between wet and solid swallows and how this was managed clinically. Data was collected from consecutive patients at a single National Health Service Trust (UK) site over a 6-month period. HRM was performed using a 36-channel HRM solid state catheter with impedance (Medtronic ManoScan™ ESO HRM) following the upright study CC4 protocol[2]. All patients had 5 mL saline swallows and those with dysphagia or abnormal primary swallows underwent solid swallows (rice test meal)[3].

Results

69 patients underwent HRM during the 6-month period. 51 studies included solid swallows, 61% (n=31) showed agreement between wet and solid CC4 findings and 39% (n=20) showed disagreement. Of those with discordance, it was concluded that 9 were inconclusive due to mixed appearances. In 7 studies the solid swallows were deemed more clinically relevant and in 4 studies the liquids swallows best reflected the clinical context.
10 patients had abnormalities detected on wet swallows but normal solids, 50% of which showed ineffective oesophageal motility (IOM) and 50% showed oesophago-gastric junction outflow obstruction (OGJOO). Of the patients with OGJOO on wet swallows and normal solids, 3 were concluded to be normal due to a lack of symptoms, good bolus clearance on HRM and normal endoscopy and barium swallow results. One was deemed inconclusive as the patient was symptomatic to bolus hold-up measured on HRM. One was concluded as OGJOO due to abnormal rapid drink challenge, upright swallows and supine swallows.
Of the 5 studies showing IOM on liquid swallows but normal solids, 2 were overall concluded to be normal due to a lack of symptoms. 2 were concluded as IOM, although only one was symptomatic to ineffective swallows. Both reports did, however, mention evidence of peristaltic reserve. One study was concluded inconclusive as possible IOM.
3 patients who had normal liquid swallows had abnormalities on solids. One showed IOM on solids which was concluded as insignificant due to a lack of symptoms. One had hypercontractile oesophagus which was concluded as significant due to the presence of symptoms[3]. The other showed symptomatic OGJOO with solids. This was classed as inconclusive as the patient had normal bolus clearance on barium swallow.

Conclusion

More patients had abnormalities on liquid swallows which normalised on solids, despite studies indicating increased motility disorder diagnosis with solid swallows[4]. Test analysers placed greater significance on solid swallow findings compared to liquids. However, many tests were reported as inconclusive. Tests with abnormal liquid swallows but normal solids frequently had differing conclusions, in part due to adjunctive test findings and reported symptoms. This emphasizes the importance of symptoms and overall clinical judgement when reporting. Future CC iterations should consider discordant findings and offer guidance on what is clinically relevant during HRM studies.

References

[1] Yadlapati, R. Kahrilas, P.J. Fox, M.R. et al. 2021. Esophageal motility disorders on high-resolution manometry: Chicago classification version 4.0^©. Neurogastroenterology and Motility. 33(1).
[2] Fox, M.R. Sweis, R. Yadlapati, R. Pandolfino, J. Hani, A. Defilippi, C. Jan, T. and Rommel, N. 2021. Chicago classification version 4.0^© technical review: Update on standard high-resolution manometry protocol for the assessment of esophageal motility. Neurogastroenterology and Motility. 33(4).
[3] Ang, D. Misselwitz, B. Hollenstein, M. Knowles, K. Wright, J. Tucker, E. Sweis, R. and Fox, M. 2017. Diagnostic yield of high-resolution manometry with a solid test meal for clinically relevant, symptomatic oesophageal motility disorders: serial diagnostic study. The Lancet Gastroenterology & Hepatology. 2(9), 654-661.
[4] Sharma, P. and Yadlapati, R. 2022. Evaluation of Esophageal Motility and Lessons from Chicago Classification version 4.0. Current Gastroenterology Reports. 24(1):10-17.

Introduction

While the clinical trial (JCOG1009/1010) evaluating the efficacy and safety of endoscopic submucosal dissection (ESD) for intramucosal (T1a(M)) undifferentiated early gastric cancer (UD-EGC) of the predominant type measuring <2 cm not associated with ulceration showed a favorable 5-year survival outcome (99.3% (95% confidence interval: 97.1-99.8 )), the 10-year prognosis is still uncertain. We have followed the patients for 10 years.

Aims & Methods

Main eligibility criteria were endoscopically diagnosed cT1a/N0/M0, single primary lesion, size ≤2 cm, no ulceration, and histological components of undifferentiated adenocarcinoma in biopsy. Based on the histologic findings after ESD, additional gastrectomy was indicated if the histopathologic examination did not meet the criteria for curative resection. The primary endpoint was 5-year overall survival (OS) of the undifferentiated-predominant type group, and 10-years follow-up of patients was planned.

Results

Of a total of 346 patients enrolled between February 2011 and May 2013 from 49 institutions, 337 were eligible and all eligible patients underwent ESD. Histopathologic findings of the resected specimens showed undifferentiated predominant cancer in 275 patients while one patient could not be evaluated due to emergent surgery for a perforation during ESD. Of the 275 patients, 195 whose ESD was judged to result in a curative resection were followed up without additional treatment, and 73 of the remaining 79 patients whose ESD was judged to result in a non-curative resection received additional gastrectomy. Among the 275 patients with UD-EGC, one patient experienced a metastatic recurrence 3,034 days after ESD. The 10-year OS and relapse-free survival (RFS) of patients with undifferentiated-predominant type were 96.2% (95% confidence interval: 93.1-97.9) and 95.7% (95% confidence interval: 92.4-97.6), respectively, while the 10-year OS and RFS for all 346 enrolled patients were 95.1 % and 94.7 %, respectively.

Conclusion

ESD for UD-EGC with tumor size of 2 cm or less is the standard treatment, with excellent 10-year survival results as well as in the 5-year period.

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) is essential for managing liver transplant complications. Dilations, stent placement, and stone removal are typically performed during these procedures. Post-ERCP pancreatitis (PEP) occurs in 5-8% of the general population, but its incidence in liver transplant (LT) patients remains undefined. This special group exhibits characteristics that warrant dedicated analysis (immunosuppression, altered anatomy and complexity of ERCP). Conflicting data exist in literature and risk factors in LT patients are poorly understood. This study aims to clarify the incidence of PEP in this population and identify specific risk factors for its development.

Aims & Methods

A total of 189 patients (271 ERCPs) were analyzed between 2022 and 2024. The first part of the study included 75 LT recipients; the second part evaluated the general population composed of 75 LT and 114 non LT. Data collected included demographics, medical history, procedural details and PEP occurrence. Statistical analysis comprise univariate and multivariate models, adjusting for repeated procedures on the same patient when necessary.

Results

The incidence of PEP in LT patients is significantly higher (21.3%) compared to non-LT patients (8.7%). Liver transplantation was a notable risk factor for PEP (p=0.014), with a trend in multivariate analysis (OR=2.29; p=0.078). Difficult cannulation strongly correlated with PEP in both groups, particularly in LT patients (OR=4.86; p=0.013). In LT recipients, female sex (OR=3.11; p=0.094), shorter transplantation-to-ERCP interval, and dual immunosuppressive therapy showed a potential risk association. Conversely, prior biliary stent placement reduced PEP risk (OR=0.131; p=0.001).

Conclusion

LT recipients have a higher PEP risk due to procedural and patient-specific factors. Female sex plays a greater role than in the general population, while dual immunosuppressive therapy and shorter time from transplant are potential risk factors. Conversely, biliary stents provide a possible protective effect. These findings underscore the need for a larger sample size to validate emerging risk factors and develop targeted preventive strategies.

References

1. Catron TD, Shipley L, Johnson D, et al. Differences in post-ERCP adverse event rates between post-liver trans-
plant patients and patients with native hepatobiliary anatomy. Gastrointestinal Endoscopy. 2019
2. Li GZ, Wang F, Fang J, Zha HL, Zhao Q. Risk Factors for Post-Endoscopic Retrograde
Cholangiopancreatography Pancreatitis: Evidence from 1786 Cases. Med Sci Monit. 2018
3. Ambrus RB, Svendsen LB, Hillingsø JG, Hansen ML, Achiam MP. Post-endoscopic retrograde
cholangiopancreaticography complications in liver transplanted patients, a single-center experience. Scand J
Surg. 2015

Introduction

Gastrointestinal endoscopy advancements have improved diagnostics and treatment but also increased the risk of adverse events, potentially affecting the psychological well-being of practitioners. This study aims to assess the psychological state experienced by Portuguese gastroenterologists following endoscopic adverse events in endoscopic procedures.

Aims & Methods

A nationwide online survey was conducted between November 2024 and January 2025, with invitations sent to all registered Portuguese gastroenterologists (n=709). Psychological state was assessed using validated scales assessing psychological distress (DASS-21), professional quality of life (ProQOL-5), self-compassion (SCS-12), and shame feelings (OAS2). Results are presented as median (Mdn) and interquartile range (IQR).

Results

Seventy gastroenterologists participated in the study (Mdn age 41 years; experience 11 years; both IQR 11), with a 9.87% participation rate. Nearly all (n=69) had encountered adverse events, with most reporting 1–5 incidents. None sought psychological support after the adverse events, 6 faced legal repercussions, and 3 discontinued specific techniques. DASS-21 had a Mdn of 6.00 (IQR 12.00) for stress (mild if <10), 4.00 (IQR 8.00) for anxiety (mild if <6), and 4.00 (IQR 6.00) for depression (mild if <10). ProQOL-5’s total score Mdn was 41.00 (IQR 6.50) for compassion satisfaction, 25.5 (IQR 7.00) for burnout, and 24.00 (IQR 6.25) for traumatic stress, all within the moderate range (23–41). OAS2 shame score was 16.00 (IQR 7.30). Self-compassion showed a Mdn of 3.46 (IQR 1.00; moderate if 2.3–3.5). Gastroenterologists with legal repercussions had higher compassion satisfaction (52.50 vs. 33.33; p = 0.025). Those who discontinued procedures reported higher anxiety levels (56.17 vs. 31.88; p = 0.026), but no other significant differences were found.

Conclusion

This is the first published study assessing the psychological state of adverse events on gastroenterologists. While most reported mild to moderate distress, legal repercussions were associated with higher compassion satisfaction, and stopping procedures correlated with higher anxiety. Findings suggest a need for psychological support after endoscopic adverse events, and for research on their impact on gastroenterologists.