Introduction

Glucagon-like-peptide-1 receptors agonists (GLP1-RA) are approved for treatment of diabetes mellitus (DM) and weight reduction. There is an increase in the use of these medications.

Aims & Methods

We aimed to investigate the association between GLP1-RA use and findings of gastric residue on esophagogastroduodenoscopy (EGD).
​A multicenter, retrospective study included all EGDs conducted across seven gastroenterology departments between the years 2020-2023. Demographics, procedural indications, and findings from the EGD were collected. EGDs with the diagnosis of “poor preparation” or described as a poor preparation in the endoscopist’s report were considered as gastric residue.

Results

120,879 EGDs were included in the analysis. Of these, 1671 patients treated with GLP1-RA were compared to 119,208 without GLP1-RA treatment. Of the GLP1-RA group, 93 (5.6%) had gastric residue compared to 2327 (2.0%) among the non-GLP1-RA group (p<0.001). Sup-group analysis showed excess gastric residue in 71 (6.2%) of the 1141 DM patients treated with GLP1-RA compared to 307 (3.0%) of the 10,152 DM patients without GLP1-RA treatment (p<0.001). Additionally, 22 (4.2%) of 503 non-DM patients treated with GLP1-RA had gastric residue compared to 2065 (2.0%) of the non-DM non-GLP1-RA group (n=109,056) (p<0.001). In multivariate analysis, DM and GLP1-RA were both found to be independent risk factors for excess gastric residue (OR=2.0, p<0.001, and OR=2.1, p<0.001 respectively).

Conclusion

Our results may have important clinical relevance for EGD preparation among GLP1-RA treated patients, either requiring a longer fasting time prior to EGD or holding the medication prior to EGD according to the half-life of the drug. Prospective studies are needed to investigate the best approach for these patients.

Introduction

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) induce weight loss, and have been associated with an overall decreased risk of esophageal cancer. Obesity is strongly associated with esophageal adenocarcinoma and substantial weight loss may decrease the risk of this malignancy, whereas weight loss does not decrease the risk of esophageal squamous cell carcinoma. We examined the hypotheses that GLP-1RA treatment decreases the risk of esophageal adenocarcinoma.

Aims & Methods

This population-based case-control study included all cases of esophageal adenocarcinoma and esophageal squamous cell carcinoma in adults who had dispensed medication for type 2 diabetes in Denmark (2007-2020), Finland (2011-2018), Iceland (2009-2019), Norway (2007-2019), or Sweden (2007-2020). For each case participant, >10 control participants who had dispensed medication for type 2 diabetes were randomly sampled from the general populations. Data came from well-validated nationwide health-data registries with prospectively collected data. Multivariable logistic regression provided odds ratios (OR) for esophageal adenocarcinoma and esophageal squamous cell carcinoma with 95% confidence intervals (CI), adjusted for sex, age, calendar year, country, comorbidity, obesity, alcohol overconsumption, and tobacco smoking.

Results

This study included 2,909 case participants with esophageal adenocarcinoma, 670 case participants with esophageal squamous cell carcinoma, and 55,408 control participants. The risk of esophageal adenocarcinoma was not decreased in GLP-1RA users compared with non-users (adjusted OR 1.3, 95% CI 1.1-1.5). However, the risk of esophageal squamous cell carcinoma was decreased (adjusted OR 0.5, 95% CI 0.3-0.8).

Conclusion

Standard GLP-1RA treatment in patients with type 2 diabetes might not decrease the risk of esophageal adenocarcinoma. Confounding by indication may have been the most important, or even the sole, contributor to the decreased risk of esophageal squamous cell carcinoma observed, although anticarcinogenic mechanisms of GLP-1RAs other than weight loss cannot be ruled out.

Introduction

Obesity and type 2 diabetes mellitus (T2DM) represent growing global health challenges, affecting millions of individuals worldwide. Glucagon-like peptide-1 receptor agonists (GLP-1RAs) have emerged as a cornerstone in the management of both conditions due to their metabolic benefits, including weight loss and glycemic control. European cohort studies have reported a high prevalence of gastrointestinal symptoms – including nausea, vomiting and early satiety among patients using GLP-1RAs. In parallel, increased rates of residual gastric content (RGC) during upper endoscopy have raised safety concerns, prompting reevaluation of pre-procedural fasting guidelines. However, data on the effects of GLP1-RA on the gastrointestinal (GI) tract in Asian patients is limited.

Aims & Methods

Our primary aim was to characterize a cohort of patients who received treatment with GLP1-RA in terms of their gastrointestinal side effects and presence of RGC during upper endoscopy. The secondary objective was to compare the afore-mentioned variables between 2 groups: oral versus subcutaneous mode of administration. We conducted a retrospective cross-sectional cohort study of 139 Asian adult patients with T2DM and/or obesity who were prescribed GLP-1RAs at a tertiary hospital between 01 January 2022 to 01 January 2023. Data collected included demographics, anthropometric measurements, co-morbidities, GI symptoms and upper endoscopy findings. Upper endoscopy images were analysed and adequacy of mucosal visibility was graded using the POLPREP scale. Patients were further stratified into two subgroups based on route of GLP-1RA administration: oral versus subcutaneous. Statistical analysis compared symptom prevalence and POLPREP scores across subgroups using chi square test, with p <0.05 considered statistically significant.

Results

A total of 139 patients were analysed. 19.4% of patients had GLP-1RA prescribed for T2DM, 21.6% for Obesity, and 58.8% for both. The most commonly prescribed GLP-1RA was Liraglutide (33.8%) followed by oral Semaglutide (28.1%). Majority of patients (66.9%) did not have any GI side effects. The most commonly reported GI symptoms were abdominal bloating (15.8%), nausea (7.9%) and early satiety (4.3%). 13.7% of patients underwent upper endoscopy with 89.5% having a POLPREP score of 3 with no significant complications reported. None of the patients withheld GLP-1RA prior to endoscopy. Upon stratifying patients based on route of administration, analysis revealed that patients on oral GLP-1RAs were more likely to report nausea compared to those on subcutaneous formulations (15.8% vs 5.0%, p=0.03). There were no significant differences in the other GI symptoms or POLPREP scores.

Conclusion

Based on our Asian cohort, these findings suggest that GLP-1RAs have an acceptable GI symptom profile with a potential route-dependent difference in symptomatology. In addition, discontinuing these drugs prior to upper endoscopy may be unnecessary.

References

1. Camilleri et al. Effects of GLP-1 and other Gut Hormone Receptors on the Gastrointestinal tract and implications in clinical practice. Am J Gastroenterol 2024;119:1028-1037
2. Nadeem et al. Effects of glucagon-like peptide-1 receptor agonists on upper endoscopy in diabetic and nondiabetic patients. Gastrointestinal Endoscopy 2024.
3. Jalleh et al. Gastrointestinal effects of GLP-1 receptor agonists: mechanisms, management, and future directions. Lancet Gastroenterol Hepatol 2024;9:957-64
4. Facciorusso et al. Effects of Glucagon-like peptide-1 receptor agonists on upper gastrointestinal endoscopy: A meta-analysis. Clinical Gastroenterol and Hepatol 2024.
5. Romańczyk et al. Scoring system assessing mucosal visibility of upper gastrointestinal tract: The POLPREP scale. J Gastroenterol Hepatol 2022 Jan;37(1):164-168.

Disclosure

Nothing to disclose

Introduction

Glucagon-like-peptide-1 receptors agonists (GLP1-RA) are approved for treatment of diabetes mellitus (DM) and weight reduction.

Aims & Methods

We aimed to investigate the association between GLP1-RA use and poor preparation of colon.
Methods: A multicenter, retrospective study was conducted, including all colonoscopies performed across seven gastroenterology departments from 2016 to 2022. Patients who had undergone colon surgery or had conditions such as Parkinson's disease, cerebrovascular accidents (CVA), scleroderma, amyloidosis, gastroparesis, or those taking narcotic or anti-cholinergic drugs, as well as those with incomplete preparation data, were excluded from the study. The rates of "poor preparation" were collected.

Results

4,104 patients treated with GLP-1 receptor agonists (GLP-1 RA) (age 60 ± 0.2 years, 55.6% females) to 294,643 patients not treated with GLP1 RA (age 56.06 ± 13 years, 52.6% females), these patients were undergoing their first colonoscopy. The study found that 409 (10%) of GLP1 RA patients had poor colonic preparation, compared to 16,811 (5.7%) of patients not treated with GLP1 RA. Subgroup analysis revealed that 173 (8.3%) non-diabetic patients treated with GLP1 RA had poor colonic preparation, compared to 14,810 (5.4%) non-diabetic patients not treated with GLP1 RA (p<0.001). Among diabetic patients, 236 (11.7%) treated with GLP1 RA had poor colonic preparation, compared to 2,001 (9.7%) diabetic patients not treated with GLP1 RA (p=0.004). Multivariate analysis showed that both diabetes mellitus (DM) and treatment with GLP-1 RA were independent risk factors for poor colonic preparation, with odds ratios of 1.7 (p<0.001) and 1.3 (p<0.001), respectively.

Conclusion

GLP-1 RA among diabetes and non-diabetic have an impact on colonic preparation, indicating that these patients may require special consideration and tailored recommendations for their colonoscopy preparation. To establish the most effective approach for these patients, prospective studies are needed.

Introduction

Gastroparesis (GP) is defined as symptomatic delayed gastric emptying. The most frequent etiologies are diabetes mellitus, after esophageal or gastric surgery and about a third of patients have idiopathic GP. The gastric emptying study by using a scintigraphy scintigraphy (GES) is considered as a principal diagnostic method. Endoscopic pyloromyotomy (G-POEM) is a method improving symptoms in about 60-70% of patients with GP. Its effect on gastric emptying remains controversial.

Aims & Methods

We performed a retrospective single-center analysis to assess the clinical efficicacy of G-POEM based on GES parameters. Between 2016 – 2024, a total of 72 patients with GP (confirmed by scintigraphy) underwent G-POEM and were later invited for clinical as well as scintigraphic assessment after 3, 12 and 36 months. Of these patients, 4 were excluded for missing data, incomplete follow-up data or non-standard testing meal. GES was always performed using the standardized 4 hours protocol with the standard testing meal mixed with 99Tc-DTPA. For this study, all GES were reanalyzed and the following parameters were established : residual activity after 2 hours, residual activity after 4 hours, biological halftimes of ingested activity and proximal-to-distal count ratio for time 0 (PDCR0).

Results

Mean value of GCSI before G-POEM was 3.1 and decreased to 1.6, 1.0 and 0.7 after 3, 12 and 36 months. Median value of GES after 2 hours was 60.2% before G-POEM and 38%, 32.6% and 24.2% after 3, 12 and 36 months. Median value of GES after 4 hours was 21.9% before G-POEM and 7.8%, 6.5% and 3.9% after 3, 12 and 36 months. Correlation index was weakly positive for GCSI and GES after 4 hours only for the first follow-up visit and negative for all remaining visits.
The residual activity after 2 hours and residual activity after 4 hours decreased after G-POEM during all follow-up visits (p<0,001). Mean decrease of residual activity after 4 hours was 12.89%, 15.13% and 6.7% after 3, 12 and 36 months.
Biological halftime also decreased after the procedure with statistically significant results with the mean halftime before G-POEM being 150 min and 86 min, 78.4 min and 65.8 min after 3, 12 and 36 months.
There was a difference between the diabetic and non-diabetic groups, with higher residual activity after 2 hours [median 29.6% before G-POEM, 9.0% after 3 months (p<0.001) and 11.0% after 12 months (p=0.005)] and 4 hours [median 64.8% before G-POEM, 39.4% after 3 months (p<0.001) and 37.7% after 12 months (p=0.012)] respectively in patients with diabetes.
The predictive value of PDCR0 for treatment success after G-POEM was only calculated for the first follow-up visit but was not statistically proved (p=0,712).

Conclusion

In our group of patients there is a weak correlation between the decrease of GCSI and GES early after G-POEM. The decrease in GES parameters tends to be lower in patients with diabetes compared to non-diabetic patients. Based on our data, predicting clinical success of G-POEM using PDCR0 cannot be recommended.

Introduction

Gastroparesis is common in patients with Diabetes mellitus, especially in those with poor glycemic control. Due to this association, diabetic patients are at risk of prolonged gastric transit time (PGTT) when undergoing small-bowel capsule endoscopy (SBCE).

Aims & Methods

In this investigation we aimed to assess if there was an association between hemoglobin A1c levels and PGTT in diabetic patients undergoing SBCE.
We have conducted a single-center retrospective study including all consecutive diabetic patients undergoing SBCE for two years. Patients without a valid hemoglobin A1c measurement within 3 months from SBCE were excluded. The assessed outcome was PGTT (defined as SBCE remaining in the stomach for >1h, requiring prokinetic administration and/or endoscopically assisted capsule delivery into the duodenum). Possible confounders – age, gender, inpatient status, smoking habits, diagnosis of IBD, thyroid disease, prokinetics or antidepressants regular usage - were also assessed.

Results

Final sample included 77 patients, 40 (51.9%) of them males, with a mean age of 70±10 years. PGTT occurred in 33 (42.9%) individuals. Mean hemoglobin A1c levels were significantly higher in diabetic patients with PGTT (7.4±0.8% vs 6.5±0.8%; p<0.001). In a multivariate analysis including significant confounders, hemoglobin A1c levels were still an independent predictor of PGTT (B=1.35; p<0.001). Single-handedly, hemoglobin A1c levels demonstrated very good acuity in predicting PGTT (AUC=0.80; p<0.001), with an optimal cut-off of HbA1c ≥6.8% (sensitivity 81% and specificity 73%).

Conclusion

Hemoglobin A1c levels significantly influenced the occurrence of PGTT in diabetic patients undergoing SBCE. This may eventually allow the performance of preemptive measurements to avoid PGTT in diabetic patients with poor glycemic control.

Introduction

Glucocorticoids (GC) and immunomodulators (IM) are frequently used to maintain clinical remission in various diseases, yet GC is implicated in delaying gastric ulcer healing [1], and IM is associated with post-endoscopic submucosal dissection (ESD) fever and post-coagulation syndrome on colon ESD [2]. The safety of gastric ESD in patients receiving oral GC or IM remains unknown.

Aims & Methods

This study evaluates the impact of oral GC or IM on gastric ESD outcomes, focusing on procedural safety and postoperative recovery. In a single-center, retrospective study, we analyzed clinical outcomes for 411 patients who underwent gastric ESD between April 2017 and April 2022 at our institute in Fukuoka, Japan. We compared data between patients using a GC or IM (32 patients) group and a standard group (379 patients), considering clinicodemographic characteristics and procedural details. Patients were further divided into three subgroups (SG) based on lesion size and procedure duration to consider treatment intensities: SG1 for lesions >20 mm and procedure times >60 minutes; SG2 for either lesions >20 mm or procedure times >60 minutes; and SG3 for lesions <20 mm and procedure times <60 minutes.

Results

The GC group (n=32, 93.8% on GC, median GC dose 5mg/day, 37.5% on IM) showed a higher prevalence of females (53.1%), were older (average age 77.5 vs. 73 years), and had poorer performance status than the standard group (n=379). Despite similar tumor characteristics, the GC group experienced more frequent abdominal pain (37.5% vs. 16.9%) and post-ESD fever (12.5% vs. 3.4%), resulting in longer hospital stays (average 10.8 days vs. 8.6 days) (Table). Meanwhile, the GC group's blood tests showed less elevation in white blood cell (WBC) and C-reactive protein (CRP) levels compared to the standard group. Intraoperative perforation occurred in 6.2% of the GC group but was managed conservatively without any cases of delayed perforation. Subgroup analysis revealed that SG1 experienced the most significant increases in abdominal pain, post-ESD fever, and WBC/CRP levels (Table).

Conclusion

Gastric ESD in patients on GC or IM were feasible but poses higher procedural risks and more frequent postoperative complications, particularly at higher treatment intensities. These findings highlight the need for customized procedural strategies and increased postoperative care to enhance outcomes for this vulnerable patient population.

References

[1]Reitman D, Sacks HS, Smith H Jr, et al. Association of adrenocorticosteroid therapy and peptic-ulcer disease. N Engl J Med. 1983 Jul 7;309(1):21-4.
[2]Yamamoto S, Kinugasa H, Yamasaki Y, et al. H. Fever and electrocoagulation syndrome after colorectal endoscopic submucosal dissection for patients with immunosuppressants and steroids. DEN Open. 2021 Dec 9;2(1):e83.

Disclosure

Conflict of interest Hiroki Fukuya, Yoichiro Iboshi, Ryota Okitsu, Akito Ohkubo, Taisuke Sasaki, Shohei Hamada, Daisuke Yoshimura, and Naohiko Harada, declare that they have no conflict of interest. Eikichi Ihara participates in the funded research of Takeda Pharmaceutical Co., Ltd and belongs to an endowed course supported by companies including Ono Pharmaceutical Co., Ltd, Miyarisan Pharmaceutical Co., Ltd, Sanwa Kagaku Kenkyusho Co., Ltd, Otsuka Pharmaceutical Factory, Inc, Fujifilm Medical Co, Ltd, Terumo Corporation, Fancl Corporation, and Ohga Pharmacy.