Introduction

Repeated endoscopy is recommended to detect early-stage cancer or Barrett's oesophagus known as a precancerous lesion at the gastro-oesophageal junction (GOJ) in GERD patients. Transnasal endoscopy is considered suitable for this repeated endoscopy because of less discomfort in the throat compared to conventional (peroral) endoscopy. Thus, improvement of imaging technique at the GOJ by transnasal endoscopy is one of important issues.

Aims & Methods

To evaluate the usefulness of trasnasal endoscopy equipped with high-resolution imaging, blue laser imaging (BLI) bright and linked color imaging (LCI) for the detection short-segment Barrett’s oesophagus (SSBO). We analyzed 300 images at the GOJ acquired from 100 consecutive endoscopies performed at our medical check-up center. Each endoscopy includes white light imaging (WLI), BLI bright and LCI. Ten endoscopists independently interpreted the images on SSBO and endoscopic findings related Barrett’s oesophagus, including palisade vessels of squamo-columnar junction (SCJ) oral side (PV-O), palisade vessels of anal side (PV-A), squamous island (SI) and columnar island (CI). The quality of images for visualization was judged as: excellent visibility (score of 4), good visibility (3), fair visibility (2), or not detectable (1) were evaluated.

Results

The detection rates of each image were as follows (WLI, BLI bright and LCI respectively): SSBO 28.3%, 32.7% and 38.8%; PV-O 88.5%, 83.1% and 90.5%; PV-A 47.3%, 51.1% and 63.2%; SI 9.2%, 9.5% and 9.8%; CI 18.4%, 28.7% and 28.7%. The detection rates of LCI were significantly higher than that of WLI on SSBO, PV-O, PV-A, SI and CI, and that of BLI-bright on PV-A and PV-O. The mean visibility scores (± standard deviation) were as follows: SSBO 1.59 ± 1.02, 1.65 ± 1.03 and 1.86 ± 1.18; PV-O 3.23 ± 1.05, 3.00 ± 1.15 and 3.36 ± 1.01; PV-A 1.99 ± 1.18, 1.98 ± 1.13 and 2.40 ± 1.25; SI 1.18 ± 0.60, 1.21 ± 0.66 and 1.20 ± 0.63; CI 1.43 ± 0.95, 1.74 ± 1.19 and 1.84 ± 1.43. The visibility scores for LCI were significantly higher than that for WLI and BLI-bright on SSBO and all items of related findings (<0.001). Moreover, PV-A showed the strongest correlation with SSBO on visibility score among endoscopic findings related to SSBO (R=0.500; p<0.001).

Conclusion

These results suggest that LCI with transnasal endoscopy is quite effective for the observation GOJ and detecting SSBO.

Introduction

Anemia is a common and often underdiagnosed condition in the elderly population. Digestive endoscopy plays a pivotal role in the etiological workup, particularly to rule out serious underlying causes such as malignancies or peptic lesions. However, the diagnostic yield of such procedures in routine clinical practice remains variable and underreported, especially in resource-limited settings.

Aims & Methods

To assess the diagnostic yield of digestive endoscopy in the investigation of anemia in elderly patients, with a particular focus on iron deficiency anemia (IDA) and vitamin B12 deficiency, and to identify specific endoscopic findings associated with these etiologies.
We conducted a retrospective descriptive study over a 6-month period. The study included all patients aged 65 years and older who underwent esophagogastroduodenoscopy (EGD) and/or colonoscopy as part of the diagnostic evaluation for anemia. Data collected included demographic information, clinical symptoms, laboratory parameters (including hemoglobin, ferritin, vitamin B12 levels), endoscopic findings, and histopathological results when available.

Results

A total of 252 patients were included in the analysis. Among them, 44 patients (17.5%) with a mean age of 71 years [68-82], had confirmed IDA, and six patients (2.4%) presented with vitamin B12 deficiency anemia, associated in all cases with histologically confirmed fundic atrophy.
In univariate analysis, IDA was statistically correlated with the presence of peptic esophagitis (p=0.04), gastric neoplasia (p=0.001), erosive gastropathy (p=0.02), and Helicobacter pylori gastritis (p=0.04). It was also weakly correlated with the presence of colorectal cancer (p=0.05).
Colonic angiodysplasias and colonic polyps were not associated with IDA in this cohort (p=0.1 and p=0.4, respectively).

Conclusion

Digestive endoscopy, particularly EGD, remains a cornerstone in the diagnostic algorithm of anemia in the elderly. It enables the identification of a wide range of underlying pathologies, from inflammatory lesions to malignancies, and guides appropriate therapeutic interventions. Early endoscopic evaluation should be encouraged in this population to prevent diagnostic delays and improve outcomes.

Introduction

Hyponatremia is a frequent complication of cirrhosis and is a prognostic factor correlated with the severity of cirrhosis and influencing survival and the occurrence of complications, but this relationship is not yet well defined.

Aims & Methods

This was a single-centre retrospective descriptive and analytical study, including all cirrhotic patients admitted to our department in ascitic decompensation with hyponatremia between January 2019 and march 2025. The natremia threshold of 130 mmol/l was chosen because it is widely accepted to define hyponatraemia in cirrhotic patients. In our study, we compared 2 groups of patients: group A: fluid restriction + albumin infusion and group B: fluid restriction alone. Predictive factors of hyponatremia development and its impact on the outcome were evaluated. The aim of this study was to identify predictive factors of hyponatremia in cirrhotic patients with ascites, assess its prognostic impact on complications and survival, and compare the effectiveness of two treatment strategies—fluid restriction alone versus fluid restriction combined with albumin infusion—in correcting hyponatremia and improving clinical outcomes.

Results

Out of a total of 127 cirrhotic patients, forty patients with ascites and hyponatraemia (Na < 130 mmol/L) were included in the comparative analysis. These patients were divided into two groups: twenty patients received fluid restriction combined with albumin infusion (group A), and twenty patients received fluid restriction alone (group B). The mean age across both groups was 54.7 years, ranging from 19 to 80 years, with a sex ratio M/F of 0.7.
The causes of liver cirrhosis in our patients were: autoimmune (n=15), viral (n=11), undetermined (n=9), metabolic (n=2), genetic (n=2) and alcoholic (n=1).
Child-Pugh stage was B in 55% and C in 45%. The mean MELD score was 18 [7-48]. The prevalence of dilutional hyponatremia as defined by a serum sodium concentration ≤130 mmol/L or ≤135 mmol/L was 10.5% and 31.4% respectively.
The mean MELD score was 18, ranging from 7 to 48. The prevalence of dilutional hyponatremia, defined as serum sodium ≤130 mmol/L or ≤135 mmol/L, was 10.5% and 31.4%, respectively. A serum sodium level ≤130 mmol/L was significantly associated with more advanced liver disease, including Child-Pugh C (OR=7.84; p<0.001) and MELD >16 (OR=6.76; p=0.001).
Group A demonstrated a significantly greater improvement in natremia (mean increase of 4.5 mmol/L versus 1.2 mmol/L in group B; p=0.02), as well as a lower incidence of complications such as hepatic encephalopathy and hepatorenal syndrome. Although the difference in global survival at one year between the two groups (33.3% in group A vs. 12.5% in group B) The main precipitating factors of hyponatremia identified were excessive diuretic use (n=18), spontaneous bacterial peritonitis (n=12), gastrointestinal bleeding (n=6) and constipation (n=4). In several cases (n=8), multiple triggers were observed concurrently. The presence of hyponatremia was associated with a higher incidence of complications during hospitalization. Survival without complications was significantly reduced in patients with hyponatremia when a serum sodium concentration ≤135 mmol/L was used as the threshold (p=0.012). Moreover, survival free from hepatic encephalopathy and hepatorenal syndrome was significantly lower in hyponatremic patients (p<0.0001).
Analysis of prognostic factors revealed that serum sodium ≤130 mmol/L (HR=2.92; p=0.004), Child-Pugh C stage (HR=3.45; p=0.002), MELD score >18 (HR=2.67; p=0.007), and development of hepatic encephalopathy or hepatorenal syndrome during hospitalization (HR=4.21; p<0.001) were significantly associated with poor outcomes. Treatment of hepatic encephalopathy included systematic use of rifaximin and lactulose alongside management of the underlying precipitating factor. Overall survival at one year was significantly lower in patients with hyponatremia (22.5% vs. 68.7%), as was mean global survival (8.3 months vs. 32.8 months; p<0.0001).

Conclusion

Low serum sodium levels were significantly associated with more advanced liver disease and increased short-term morbidity and mortality in cirrhotic patients with ascites. Our findings suggest that albumin infusion, in addition to fluid restriction, is more effective in correcting hyponatremia and may help reduce the incidence of severe complications such as hepatic encephalopathy and hepatorenal syndrome. Therefore, serum sodium appears to be a valuable prognostic marker. The clinical benefit of correcting hyponatremia should be further confirmed in larger prospective studies.

Introduction

Peroral endoscopic myotomy (POEM) is emerging as a minimally invasive therapeutic option for achalasia. Data are limited in pediatric population.
To compare the efficacy and safety of POEM in pediatric and adult patients with achalasia.

Aims & Methods

A prospective study was conducted, including all patients who underwent POEM, since August/2022, in a tertiary centre. Patients aged under 18yo were included in the pediatric group and above 18yo in adult group. Procedural-related parameters, adverse advents, pre- and post-intervention clinical, manometric and radiologic outcomes were evaluated.

Results

41 patients were included, including three children (mean age: 14.3±1.2vs.51.8±19.1yo; male gender: 100%(n=3)vs.39.5%(n=15)). According to the Chicago classification v4.0, all three children had type II achalasia (adults: type I-5.3%(n=2), type II-89.4%(n=34), type III-5.3%(n=2)). No significant differences were observed between groups in relation to clinical symptoms (Eckardt score (ES): 7.6vs.0.9;ρ=0.23; average duration of symptoms: 21vs.19months;ρ=0,36), pre-POEM integrated relaxation pressure (IRP) (36.7vs.19.0;ρ=0,11), esophagogastric junction contractile integral (EGJ-CI) (105,3vs.91,2;ρ=0.72) and barium swallow study at 1/5 minutes (4.5/5.1vs.12.6/10.0;ρ=0,17/0.29) and post-POEM IRP (9.75vs.6.19;ρ=0.32), EGJ-CI (7vs25.20;ρ=0.30) and barium swallow study (3.45/2.20vs.2.65/1.43;ρ=0.57/0.56), evaluated at 4.3±1.3 and 8.5±2.1months of follow-up. Technical success was 100% in all groups with mean procedure time of 91.7±12.6minutes for children (vs.86.1±21.6 for adults;ρ=0.35). Clinical success was similar in both groups (ES: children-0±0 vs. adults-0.31±0.63;ρ=0.69). There were no significant differences between groups regarding intraprocedural complications (67%vs.66%;ρ=0.98), post-procedural complications or major adverse events. No mortality or need for surgery. Symptomatic gastroesophageal reflux disease (GERD), successfully treated with daily PPI, was only observed in 5(13.2%) adults (vs. 0% of pediatric patients;ρ=0.021).

Conclusion

POEM proved to be effective and safe for achalasia both in adults and pediatric patients, with no statistically significant differences regarding technical, clinical, manometric and imaging success or complications. Achalasia should be treated as early as possible, with apparently lower incidence of post-POEM GERD in pediatric patients.

References

1. Rui Mendo, Pedro Barreiro, José Rodrigues, Catarina Félix, Catarina O'Neill, Iala Carina, Joyce Chivia, Cristina Chagas; Peroral Endoscopic Myotomy for
Esophageal Achalasia in Portugal: Outcomes of the First Prospective Series. GE Port J Gastroenterol 30 April 2021; 28 (3): 162–169.

Clinical Case Summary

A 64-year-old woman with a prior diagnosis of type I achalasia underwent Heller myotomy with Dor fundoplication in 2015, which resulted in the resolution of dysphagia and regurgitation. However, she kept experiencing chest pain, which partially improved with nitro-glycerine. In 2018, due to worsening pain, she underwent high-resolution oesophageal manometry (HROM), which demonstrated absent peristalsis without oesophageal pressurization. Also, upper endoscopy was unremarkable, and timed barium swallow (TBS) revealed some tertiary contractions. By 2019, the patient received botulinum toxin injections with partial improvement. Another TBS performed in 2023 showed tertiary contractions in the distal third of the oesophagus, contributing to mild oesophageal emptying delay but without stasis. In 2024, repeat HROM revealed pan-oesophageal pressurization, except in the distal-most centimetres of the oesophagus. During rapid drink challenge, the patient reported pain. Given these findings, she was proposed for peroral endoscopic myotomy (POEM) to extend the myotomy proximally. In August 2024, she underwent a complete distal oesophageal myotomy, including the lower oesophageal sphincter and cardia. Endoscopic assessment in November showed no evidence of stasis, esophagitis, or resistance at the cardia. Latest clinical evaluation in March 2025 confirmed complete resolution of chest pain.
Conclusion: Non-cardiac chest pain is a less common yet challenging symptom to manage in achalasia. Its persistence after disease-directed treatment has been described in the literature, with its primary risk factor being its presence preoperatively¹. However, comparative data on different therapeutic approaches for achalasia-related chest pain remain limited. To our knowledge, only two similar cases have been reported in which pain persisted after Heller myotomy but improved following POEM, probably linked to the inadequate or incomplete myotomy of the oesophageal muscle layer^2,3.

References

1. Olvera-Prado H, et al. Predictive factors associated with the persistence of chest pain in post-laparoscopic myotomy and fundoplication in patients with achalasia. Front Med (Lausanne). 2022 Oct 14;9:941581.
2. Miftahussurur M, Tandan M, Makmun D, Nabi Z. Peroral Endoscopic Myotomy in a Patient with Achalasia Cardia with Prior Heller's Myotomy. Case Rep Gastroenterol. 2020 Jan 22;14(1):48-55.
3. Sato C, et al. Salvage therapy for postoperative residual chest pain due to esophageal achalasia. SAGES 2017 Annual Meeting in Houston [Abstract], https://www.sages.org/meetings/annual-meeting/abstracts-archive/salvage-therapy-for-postoperative-residual-chest-pain-due-to-esophageal-achalasia/

Introduction

During the COVID-19 pandemic the British Society of Gastroenterology (BSG) introduced interim guidelines supporting a non-biopsy pathway for the diagnosis of coeliac disease. These guidelines reflect the current recommendations of the American Gastroenterological Association (AGA). According to these guidelines, symptomatic or high risk adults with anti-Tissue transglutaminase (TTG) IgA titres ≥10× the upper limit of normal (ULN) and a positive endomysial antibody (EMA) on a repeat sample can be diagnosed without endoscopy and referred directly to a specialist coeliac clinic. Patients who do not meet these criteria should be referred for a gastroscopy (OGD) with biopsy for the confirmation of coeliac, prior to starting a gluten free diet.

Aims & Methods

To assess whether general practitioners (GPs) in the community appropriately referred patients with suspected coeliac disease in line with the AGA and BSG interim non-biopsy diagnostic criteria.
A retrospective review was conducted of all new patients referred to the Coeliac clinic in Galway university hospital between January 2023 and December 2024. Data regarding TTG level at diagnosis, EMA result, and compliance with the diagnostic pathway outlined above was collected for each new referral. This data was collected via Evolve - the hospital's electronic based patient record system.

Results

• There were 119 “new” referrals to our Coeliac Service between January 2023 and December 2024. Of these, 44 cases were known coeliac who were referred by primary care for re-engagement with the clinic, 18 were referred from secondary or tertiary care including GI surgery, Dermatology, Paediatrics, etc. 4 coincidental diagnoses (i.e. OGD performed for indications other than coeliac disease), and 5 outliers (i.e. with incomplete data or incorrectly referred to coeliac clinic) leaving 48 new coeliac cases referred from primary care.
• 18 of these referrals met the non-biopsy criteria for diagnosis (TTG ≥100 + positive EMA)
  • Within this cohort 66% (n=12) were incorrectly referred directly for an OGD which may have delayed the diagnosis of coeliac disease while the remaining 33% (n=6) were correctly referred for direct review at the coeliac clinic.
• The remaining 29 patients all had TTG values less that 10x ULN. 48% (n=14) of these patients were incorrectly referred to clinic prior to endoscopy and of greater concern, 45% (n=13) were recommended by their primary care physician to start a gluten free diet prior to any review or endoscopic procedure.
• Overall, only 44% (n=21) of referrals were compliant with the AGA/BSG guidance.

Conclusion

There is a notable gap in adherence to AGA and BSG non-biopsy coeliac diagnostic guidance in community settings. Half of patients eligible for a non-biopsy diagnosis underwent unnecessary endoscopy, and the majority of ineligible patients were commenced on a gluten free diet prior to, or without, referral for endoscopy. Further GP education is warranted to align referral practices with evidence-based pathways. Dedicated streamlined referral pathways for coeliac disease should ensure a timely diagnosis without mandatory endoscopy in those fulfilling the criteria for a non-biopsy diagnosis and facilitate a timely endoscopy prior to gluten elimination in those who require histological diagnosis.

References

Husby, S., Murray, J.A. and Katzka, D.A. (2019) ‘AGA clinical practice update on diagnosis and monitoring of celiac disease—changing utility of serology and histologic measures: Expert review’, Gastroenterology, 156(4), pp. 885–889. doi:10.1053/j.gastro.2018.12.010.
Tashtoush, L.B. et al. (2021) ‘Letter: The BSG covid‐19 interim coeliac disease guidance no‐biopsy approach is safe in adults’, Alimentary Pharmacology &amp; Therapeutics, 54(8), pp. 1090–1092. doi:10.1111/apt.16553.

Disclosure

No conflict of interest