Introduction

Endocytoscopy (EC) represents an advanced high-magnification endoscopic modality that permits in vivo cellular-level observation and assessment. However, achieving consistent high-quality staining constitutes a primary technical limitation. This study aimed to develop and validate a novel scoring scale for evaluating EC staining quality, thereby providing clinicians with a straightforward and reliable instrument to enhance procedural quality control.

Aims & Methods

We evaluated the staining quality of images from four perspectives: nuclear clarity, glandular lumen clarity, surface mucus and dye rinsing degree, and image capture quality (including issues such as improper fixation leading to virtual images, out-of-focus causing image blur, and inadequate brightness). Each evaluation criterion was scored from 0 to 2, with a total possible score of 8. The total image evaluation scores were then classified as follows: ≤2 points for Grade 1 (poor staining quality), 3-5 points for Grade 2 (moderate staining quality), and ≥6 points for Grade 3 (high Staining quality).
Data were retrospectively collected from patients undergoing colonoscopy with EC image acquisition between June 2023 and June 2024. An initial cohort comprising 1000 EC images was utilized to establish the scale's reliability, validity, and internal consistency. Subsequently, an independent validation cohort of 1000 EC images was analyzed using polynomial regression to investigate determinants of staining quality, and external validation was conducted to further evaluate the scale's applicability.

Results

A total of 2,964 and 1,946 EC-stained images were analyzed in the initial and validation cohorts, respectively, with each cohort ultimately including 500 EC-stained images. There were no statistically significant differences in age and gender within and between the initial and validation cohorts.
The scale demonstrated excellent inter-rater reliability (agreement metric = 0.992), alongside good internal consistency reliability (coefficient = 0.81) and validity (index = 0.849). A strong positive correlation was observed between Average Optical Density (AOD) values and gold standard scores (Spearman's P= 0.81). Lesion morphology, size, pathological classification, pit pattern type, and physician experience level were identified as significant factors influencing EC staining quality (all p < 0.05). A one-month training intervention utilizing the scale significantly enhanced scoring consistency among junior physicians, evidenced by increases in Kappa coefficients measuring agreement with the gold standard (Physician A: 0.61 to 0.81; Physician B: 0.66 to 0.83).

Conclusion

The Endocytoscopy Staining Quality Assessment Scale serves as a reliable and valid instrument for evaluating staining quality. Its implementation can assist endoscopists in improving their proficiency in assessing image staining quality and refining staining techniques, ultimately contributing to enhanced diagnostic accuracy and reliability during EC procedures.

Introduction

Primary sclerosing cholangitis (PSC) is a progressive and debilitating liver disease involving chronic inflammation and fibrosis of bile ducts. Vitamin D plays a critical role in anti-inflammatory and anti-fibrotic pathways, yet its impact on PSC progression remains insufficiently explored.

Aims & Methods

This study investigates the relationship between vitamin D deficiency and key outcomes in PSC patients, including biliary damage, hepatic decompensation, and survival. Sixteen PSC patients from a tertiary care outpatient clinic were included. Vitamin D status was determined via serum 25-hydroxyvitamin D3 levels, with deficiency defined as <30 ng/mL. Patients were categorized into deficient and normal vitamin D groups. Outcomes assessed included alkaline phosphatase (ALP) levels, PREsTo score for hepatic decompensation risk, and 4-year survival using the revised Mayo Risk Score (rMRS). Statistical analyses included t-tests, Mann-Whitney tests, Fisher's exact test, and Spearman’s correlation.

Results

The cohort had a mean age of 55.8±13.1 years, with equal gender distribution. Vitamin D deficiency was observed in 56.25% of patients. No significant differences were found between deficient and normal groups for ALP (106 vs. 100 U/L, p=0.71), PREsTo score (5% vs. 5%, p=0.31), or rMRS (0.2±1.1 vs. -0.2±0.6, p=0.42). Furthermore, no meaningful correlation was identified between vitamin D levels and ALP (Spearman’s rho = -0.18, p=0.56).

Conclusion

While vitamin D deficiency is prevalent among PSC patients, this preliminary analysis did not reveal a significant impact on disease progression or prognosis. These findings suggest that vitamin D’s roles in inflammation and fibrosis may not translate into measurable clinical effects within this study’s scope. Further research with larger cohorts, extended follow-up, and interventional studies on vitamin D supplementation is warranted.

Introduction

As part of the NHS Long Term Plan, ambitions were set that from 2028, an extra 55,000 people will survive for five years or more following cancer diagnosis. The aim was in part to minimize time taken from initial presentation to definitive diagnosis of cancer. “Serious non-specific symptom” (SNSS) cancer pathways were developed in 2019, to aid GPs in referral of patients with vague alarm symptoms, that were still concerning for malignancy, although maybe not fitting a pre-existing system specific, cancer referral pathway (1). Non-specific symptoms commonly include weight loss, unexplained pain and fatigue which could suggest an underlying cancer diagnosis. Within our trust, GPs can refer for an urgent CT Chest, Abdomen and Pelvis, and results are reviewed in a weekly multi-disciplinary meeting. Following this, patients are either discharged back to their GP with advice, or referred on to appropriate cancer pathways. Due to common presentations such as weight loss, this is currently run by the Gastroenterology department. Benign disease is also highlighted to GPs to consider appropriate onward referral.

Aims & Methods

This audit aimed to look at patients referred to our local SNSS pathway, evaluate cancer pick-up rate, cancer type, and benign disease prevalence. To date, there are little relevant published data within the UK, despite information being available within Europe, such as one Danish study which detected a pick-up rate of between 11-20% (2).  We designed a retrospective audit looking at all patients referred via the SNSS pathway from February 2023 to September 2023 in South Tyneside and Sunderland NHS Foundation Trust. Electronic notes were reviewed. We looked at referral indication, inappropriate referrals (those that met pre-existing suspected cancer pathways), cancer pick-up rate, type, and whether this was metastatic at diagnosis.

Results

502 patients were reviewed, over 30 MDT meetings. This was evenly split between male (45%) and female (55%) patients, with an average age of 71 years. The most common symptom prompting referral was weight loss, in 74.1% of referrals. Of these patients, 7.5% were diagnosed with cancer. Other common symptoms included fatigue (22.5%), abdominal pain (20.7%), anorexia (13.9%) and generalised pain (13.1%).  The overall cancer pick-up rate was 8.6%, with 43 patients found to have a cancer diagnosis. Almost 6% of patients were inappropriately referred to this pathway, having met criteria for pre-existing system specific cancer pathways. However, excluding these patients, overall cancer pick-up rate remained at 8.4%. The most common primary cancers were upper gastrointestinal (25.6%), lung (23.3%) and haematology (11.6%). 37.2% of cancer diagnoses had metastatic disease. Benign pathology was detected in 65% of patients.

Conclusion

Overall cancer-pick up rates in our audit, suggest that the SNSS pathway has a similar pick-up rate to existing urgent suspected cancer pathways (around 7%). This shows that the pathway is valuable in assessing vague symptoms that may not meet pre-existing diagnostic pathways but still have a high incidence of cancer. This is a valuable tool for GPs to use when they have clinical concern about cancer, but non-specific presentations. There are areas for improvement, with 5.6% of inappropriate referrals, potentially highlighting a lack of awareness of pre-existing criteria for cancer diagnostic pathways. We suggest that further national analysis could be done, on impact and effectiveness of SNSS pathways, including long-term outcomes of patients, as improvements in 5-year cancer survival remain unclear.

References

1. NHS Cancer Programme: Faster Diagnosis Framework (2019) , www.england.nhs.uk/cancer/faster-diagnosis [accessed 21 March 2025]
2. Grønnemose, R.B., Hansen, P.S., Worsøe Laursen, S. et al. Risk of cancer and serious disease in Danish patients with urgent referral for serious non-specific symptoms and signs of cancer in Funen 2014–2021. Br J Cancer 130, 1304–1315 (2024). https://doi.org/10.1038/s41416-024-02620-y

Introduction

It is well known that head and neck squamous cell carcinoma (HNSCC) often occur in patients with esophageal squamous cel carcinoma (ESCC) synchronously or metachronously. As a result of improvements in endoscopic system and observation techniques, the number of patients with advanced ESCC who are detected superficial HNSCC before treatment is increasing. However, subsequence clinical course of superficial HNSCC in patients who were treated with systemic neoadjuvant triplet chemotherapy for advanced ESCC has been unknown.

Aims & Methods

The aim of this study is to clarify the influence of neoadjuvant docetaxel, cisplatin, and 5-fluorouracil (DCF) therapy for superficial HNSCCs and clinical course of these lesions. The patients with advanced ESCC and superficial HNSCC, which were diagnosed by biopsy, who were treated with neoadjuvant DCF therapy for esophagectomy at our institution between January 2015 and December 2022 were retrospectively included. We excluded the patients who had a history of surgery or radiotherapy for HNSCC, chemotherapy within 5 years for any malignancy, or no endoscopic observation after the start of DCF therapy. At our institution, the endoscopic assessments were routinely performed for ESCC and HNSCC after the completion of each course of DCF therapy and reported the morphological changes in HNSCC lesions. In this study, endoscopic complete response (eCR) was defined as the disappearance of visible tumors in endoscopic observation and did not require histological confirmation by biopsy. The proportion of eCR in HNSCCs after DCF therapy, and 2-year cumulative recurrence rate of HNSCCs after eCR for the patients who did not receive chemotherapy or radiotherapy after surgery were evaluated. In addition, the difference in clinicopathological features between the patients with or without achievement of eCR were evaluated.

Results

Finally, 45 patients (56 lesions) were analyzed. Thirty-nine lesions (69.6%) were in the hypopharynx, 7 (12.5%) in the larynx, and 10 (17.9%) in the oropharynx. The median lesion size was 20 mm (range: 3-40 mm). Of all lesions, 45 lesions (80.4%) achieved eCR by DCF administration. There were no significant differences in tumor location, lesion size, and the number of administrated DCF course between the patients with or without achievement of eCR. On the histological evaluation using the biopsy samples, the lesions without subepithelial invasion were more likely to achieve eCR than those with invasion [88.9% vs 63.2%, P=0.035]. Seven patients who received additional chemotherapy or radiotherapy after esophagectomy and two who did not receive endoscopic assessment after esophagectomy were excluded for long-term analysis. Then, of the 39 lesions in 32 patients with achievement of eCR, 15 lesions (51.7%) had a local recurrence during the median follow-up period of 11 months (range 1.9-87 months), and the 2-year cumulative recurrence rate was 57.6%. Of these local recurrences, 12 lesions were performed with endoscopic laryngopharyngeal surgery, two with radiotherapy, and the other was not treated because of progression of ESCC.

Conclusion

Superficial HNSCCs mostly achieved eCR after neoadjuvant DCF therapy for locally advanced ESCC, however, more than half of them had a local recurrence thereafter. Therefore, the appropriate endoscopic follow-up after esophagectomy, early detection of local HNSCC recurrence, and therapeutic intervention were necessary.

Clinical Case Summary

Introduction: Sclerosing encapsulating peritonitis (SEP) is a rare cause of intestinal obstruction, characterized by a fibrous membrane that encases the small bowel. First described by Owtschinnikow in 1907, SEP is classified into primary (idiopathic) and secondary forms, with secondary forms linked to conditions like peritoneal dialysis, abdominal tuberculosis, and abdominal surgery. Despite its rarity, SEP should be considered in the differential diagnosis of unexplained bowel obstruction.
Observation: A 38-year-old male with a history of peritoneal tuberculosis, treated for four months with antitubercular medications, presented with abdominal pain, distension, weight loss (8 kg in 3–4 months). Laboratory tests included a positive Quantiferon test, ascitic fluid analysis showed an exudative effusion with elevated ADA levels, and CT imaging revealed peritoneal effusion, necrotic lymph nodes, and thickened small bowel loops.
Four months later, the patient developed signs of acute small bowel obstruction. CT scan confirmed the diagnosis of SEP. Figure 1: Image of abdominal CT showing a pseudo-sac formed by agglutinated small bowel loops.
Surgical exploration revealed a fibrous capsule encasing the small intestine with signs of ischemia. Adhesiolysis was performed, followed by resection of the ischemic bowel segment and the creation of a double ileostomy due to significant bowel retraction.
Histopathology of the omental biopsy showed peritoneal sclerosis with inflammatory changes without granulomas or malignancy. The resected small bowel displayed ulcerated acute inflammation without evidence of malignancy.Figure 2: Histological image showing peritoneal sclerosis.
Conclusion: This case highlights the importance of considering SEP in patients with abdominal tuberculosis who develop bowel obstruction. Early diagnosis, often made intraoperatively, and timely surgical intervention are crucial for managing this rare but severe complication.

References

1. Sharma, Supran, et al. “Sclerosing Encapsulating Peritonitis in Tuberculosis.” International Journal of Contemporary Surgery, vol. 5, no. 2, 2017, p. 1. DOI.org (Crossref), https://doi.org/10.5958/2321-1024.2017.00028.9.

2.Soualili, Nadim Abdelhak, et al. “Péritonite Sclérosante Encapsulante Idiopathique de Découverte Fortuite: À Propos d’un Cas.” PAMJ Clinical Medicine, vol. 13, 2023. DOI.org (Crossref), https://doi.org/10.11604/pamj-cm.2023.13.6.40911.

Disclosure

Conflict of Interest: The authors declare no conflict of interest.

Introduction

Chronic atrophic gastritis (CAG) is a known precancerous condition for gastric cancer (GC). Low serum PG-I levels are proposed as a non-invasive marker for chronic atrophic gastritis of the stomach body, but the adequate upper cut-off for diagnosis remains controversial, as values ranging from 30 to 50 mcg/L currently are considered a “grey-zone”.

Aims & Methods

Aim: To identify patients with body chronic atrophic gastritis (CAG) amongst subjects with PGI levels ranging between 30 and 50 mcg/L (within the so-called “grey zone”) using a PPI test.
Methods: We selected 102 patients with PGI< 60 mcg/L. According to PG1 levels, this population was divided into 5 groups: Group A (PGI< 30 mcg/L); Group B (PGI 31-35 mcg/L); Group C (PGI 36-40 mcg/L); Group D (PGI 41-50 mcg/L.); Group E (PGI 51-60 mcg/L). All patients underwent to PPI test (Esomeprazole 40 mg daily for 1 week). By using the ROC curve, a cut-off of 30% increase from baseline PG1 was chosen. For each patient, the OLGA Staging was performed.

Results

A statistically significant relationship between PG1 levels and OLGA staging was found, being 100% in the Group of PG1<30mcg/L. PGI levels (cut-off 30% of delta increase) resulted in a positive predictive value of 95%, a negative predictive value of 86%, with an 83% and 96% sensitivity and specificity, respectively, for diagnosing atrophic gastritis of the stomach body.

Conclusion

The PPI test allows the diagnosis of 93.87% (46 out 49 subjects) of atrophic gastritis of the stomach body, with a cut-off between 41-50 mcg/L.

References

1. Chapelle N, Martin J, Osmola M, Hémont C, et al.. Serum pepsinogens can help to discriminate between H. pylori-induced and auto-immune atrophic gastritis: Results from a prospective multicenter study. Dig Liver Dis. 2023 Oct;55(10):1345-1351.
2. Lahner E, Zagari RM, Zullo A, et al. Chronic atrophic gastritis: Natural history, diagnosis and therapeutic management. A position paper by the Italian Society of Hospital Gastroenterologists and Digestive Endoscopists [AIGO], the Italian Society of Digestive Endoscopy [SIED], the Italian Society of Gastroenterology [SIGE], and the Italian Society of Internal Medicine [SIMI]. Dig Liver Dis. 2019 Dec;51(12):1621-1632
3. Di Mario F, Crafa P, Barchi A, et al.. Pepsinogen II in gastritis and Helicobacter pylori infection. Helicobacter. 2022 Apr;27(2):e12872.
4. Crafa P, Franceschi M, Rodriguez Castro KI, et al Functional Dyspesia. Acta Biomed. 2020 Jul 9;91(3):e2020069.
5. Wang X, Lu B, Meng L,et al. The correlation between histological gastritis staging- 'OLGA/OLGIM' and serum pepsinogen test in assessment of gastric atrophy/intestinal metaplasia in China. Scand J Gastroenterol. 2017 Aug;52(8):822-827.

Disclosure

Prof. Di Mario declares: Consultancy agreement with Biohit

Introduction

Ineffective esophageal motility (IEM) is a manometric diagnosis based on the rate of failed/ineffective swallows, consistently associated with Gastro-Esophageal Reflux Disease (GERD). Chicago 4.0 classification (CCv4.0)[1] does not include mean values of Distal Contractile Integral (DCI) in the diagnosis of IEM at High-Resolution Manometry (HRM).

Aims & Methods

The aim of this study was to explore DCI assessment as a HRM metric to refine IEM diagnosis.
Retrospective analysis of a prospectively collected database (October 2022-April 2024) was conducted on patients undergoing esophago-gastroduodenoscopy (EGD), HRM and 24-hour-pH-impedance study. Patients with indication for HRM other than GERD symptoms (achalasia, follow-up after previous foregut surgery including anti-reflux surgery or achalasia treatment), were excluded. GERD conclusive diagnosis was made according to Lyon 2.0 criteria[2]. Univariate logistic regression was computed to identify the optimal DCI cut-off for objective GERD. Multivariable logistic regression analysis were performed to identify relevant manometric predictors of objective reflux burden and to build predictive models. Models accuracy was tested through receiving operator characteristic (ROC) analysis. Sensitivity and specificity were calculated and compared between models.

Results

A total of 202 patients (M 94 [46.5%], mean age 48.5±18.6 years, BMI 22.1±7.6) were analyzed. Conclusive GERD was found in 49 patients (24.3%). IEM diagnosis was made in 40 patients (19.8%) while 162 patients (80.2%) had normal esophageal motility (NEM). ROC analysis identified DCI of 810.2 mmHg.cm.s (AUC 0.70, p<0.001) as the best cut-off in predicting objective reflux (AET>6%). The group with NEM and DCI<810.2 did not show differences with the IEM group (p>0.05). At multivariable regression analysis, IEM (CCv4.0) and Esophagogastric Junction- Contractile Integral (EGJ-CI) lost significance in predicting objective GERD (p=0.76 and p=0.91 respectively), while higher mean DCI (OR 0.41, p<0.004) and type III EGJ (OR 4.4, p<0.002) and higher mean basal EGJ pressure (MBEP) (OR 0.30, p<0.007) did remain significantly associated. At ROC analysis mean DCI combined with MBEP and type-III EGJ showed an AUC of 80.6% (p<0.001) in predicting objective GERD. We compared a model comprising MBEP, type III EGJ and IEM (CCv4.0) (Model A) vs a model comprising MBEP, type III EGJ and IEM (CCv4.0)+DCI >810.2 mmHg.cm.s (Model B). Model B was superior to Model A, showing an AUC of 80.0 vs an AUC of 78.3 (p<0.001) (Table 1.).

Table 1. Multivariable logistic regression of model A and model B in predicting AET>6%

Conclusion

Evaluation of mean DCI complements IEM diagnosis and esophageal contractility assessment, with a cut-off of 810 mmHg.cm.s to optimize IEM profiling of GERD.

References

1. Yadlapati R, Kahrilas PJ, Fox MR, et al. Esophageal motility disorders on high-resolution manometry: Chicago classification version 4.0© [published correction appears in Neurogastroenterol Motil. 2024 Feb;36(2):e14179. doi: 10.1111/nmo.14179.]. Neurogastroenterol Motil. 2021;33(1):e14058. doi:10.1111/nmo.14058
2. Gyawali CP, Yadlapati R, Fass R, et al. Updates to the modern diagnosis of GERD: Lyon consensus 2.0. Gut. 2024;73(2):361-371. Published 2024 Jan 5. doi:10.1136/gutjnl-2023-330616

Disclosure

E.V. received speaker and/or consulting fees from Sanofi/Regeneron, Falk Pharma, Apollo Therapeutics, and Aurora Biofarma. S.D. has received consultancy fees from AbbVie, Alimentiv, Allergan, Amgen, AstraZeneca, Athos Therapeutics, Biogen, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Celltrion, Dr Falk Pharma, Eli Lilly, Enthera, Ferring Pharmaceuticals, Gilead, Hospira, Inotrem, Janssen, Johnson & Johnson, MSD, Mundipharma, Mylan, Pfizer, Roche, Sandoz, Sublimity Therapeutics, Takeda, TiGenixa, UCB and Vifor; and lecture fees from AbbVie, Amgen, Ferring Pharmaceuticals, Gilead, Janssen, Mylan, Pfizer and Takeda.