Introduction

Gastrointestinal involvement is common in patients with multiple sclerosis (MS). It is estimated that 35–54% of MS patients experience constipation, while 29–51% develop faecal incontinence (FI), with both conditions frequently coexisting¹. The underlying pathophysiology is complex, as MS can affect the central nervous system at multiple levels. Despite its high prevalence and significant impact on quality of life, few studies have specifically addressed anorectal dysfunction in these patients.
The aim of our study was to describe the clinical and manometric features of MS patients presenting with constipation and/or FI.

Aims & Methods

26 patients with MS were included. High-resolution anorectal manometry (HRAM; Medtronic®), following the London protocol, and balloon expulsion test (BET; Matla Systems®) were performed in all subjects. Reference values were derived from 20 healthy controls assessed at our centre (Table 1).

Table 1. HRAM Parameters in Healthy Subjects in left lateral decubitus

Results

Faecal incontinence was observed in 21 patients (80.8%), predominantly mixed (42.3%), complete (stool and gas; 34.6%), and with Wexner scores >9 in 26.9% of cases. Constipation was reported by 15 patients (57.7%), of whom 14 (53.8%) perceived obstructive defecation. Constipation and FI coexisted in 10 patients (38%). Urinary incontinence was also present in 17 patients (65.4%).
Manometric findings revealed a tendency towards resting anal sphincter hypotonia (67.06 ± 19.85 mmHg) and reduced maximum voluntary contraction pressure (median 105.35 mmHg [IQR 86.48–149.28 mmHg]). Median contraction duration was 30 seconds (IQR 8–32 s). Rectal sensitivity assessment showed median thresholds for first sensation at 55 cc (IQR 40–70 cc), second sensation at 125 cc (IQR 100–160 cc), and maximum tolerated volume at 170 cc (IQR 135–190 cc). Sensory abnormalities were identified in 11 patients (42.3%), 4 due to hypersensitivity (15.4%) and 7 (26.9%) due to hyposensitivity.
An impaired push manoeuvre was observed in 20 patients (83.3%): type I dyssynergic defecation (DD) in 5 patients (20.8%), type II in 5 (20.8%), type III in 4 (16.7%), and type IV in 6 (25%). BET confirmed dyssynergia in 10 patients (41.7%).
*Note: Results are expressed as mean ± standard deviation or median (interquartile range), depending on data distribution. Reference values are presented as mean ± standard deviation.*

Conclusion

FI was the most prevalent symptom, often coexisting with constipation and obstructive defecation. The tendency observed in manometric findings towards anal hypotonia and hypocontractility, as well as the presence of dyssynergia in a significant number of patients, may allow the selection of individuals suitable for targeted therapies.

References

1. Dibley L, Coggrave M, McClurg D, Woodward S, Norton C. "It's just horrible": a qualitative study of patients' and carers' experiences of bowel dysfunction in multiple sclerosis. J Neurol. 2017 Jul;264(7):1354-1361.

Introduction

Functional bowel disorders are characterized by the presence of altered bowel habits with or without abdominal pain.¹ Irritable bowel syndrome (IBS) is diagnosed based on recurrent abdominal pain; however, distinctions in the clinical phenotypes of IBS subtypes and other functional bowel disorders (FBDs), such as functional diarrhea (FD) and functional constipation (FC), remain underexplored.^2,3

Aims & Methods

Aims: This study aimed to characterize the clinical presentation of IBS with predominant constipation (IBS-D) and IBS with predominant diarrhea (IBS-C), differentiating them from FD and FC, while recognizing the overlapping symptoms and the continuum between these conditions. Additionally, we examined the prevalence of psychological disorders and extra-intestinal comorbidities and identified potential mediators linking IBS to anxiety and depression.
Methods: Using data from the Rome Foundation Global Epidemiology Study, we analyzed 54,127 participants across 26 countries, including 2,195 patients with IBS. Clinical, dietary and psychological characteristics were assessed using validated questionnaires. Subgroup analyses compared IBS subtypes with FBDs, while mediation analyses (using the PROCESS macro and Baron and Kenny's method⁴) identified mediators of IBS-psychological distress relationship.

Results

As compared to patients with IBS-D, patients with IBS-C reported more severe pain characteristics, including prolonged pain episodes (50.7% vs. 47.0% of the time with pain lasting >30 minutes, p=0.030) and pain episodes that escalated to a sustained severe intensity (44.2% vs. 38.1%, p=0.026), frequently accompanied by back pain (36.7% vs. 30.9%, p<0.001). Regular use of prescribed pain medications was also more frequent in IBS-C (39.3%) than IBS-D (31.8%, p=0.004). In contrast, as compared to IBS-C, patients with IBS-D showed a stronger association of pain with changes in stool consistency (70% vs. 60% of time with pain, p<0.001) and frequency (mean 61.3% vs. 57.8% of time with pain, p=0.008). These associations remained significant in multiple regression models, which confirmed that IBS-C is more strongly linked to prolonged and escalating pain episodes, while IBS-D is more closely linked to pain associated with changes in stool frequency and consistency. As compared to FD, IBS-D patients reported greater dissatisfaction with bowel function (57.3±28.4 vs. 44.2±29.8, p<0.001), and more frequent loose stools (without constipation treatments) (60.0% vs. 50.0% of bowel movements, p<0.001), particularly after meals (60.0% vs. 40.0% of loose stools, p<0.001). IBS-C shows more severe constipation-related symptoms compared to FC (p<0.001). Mediation analyses revealed that concerns about bowel function, embarrassment discussing it, and work-related impairments partially mediated the relationship between IBS and psychological distress.

Conclusion

IBS-C is associated with more severe pain episodes, including prolonged and escalating pain, while in IBS-D pain is more strongly linked to bowel habit changes. These findings highlight the distinct clinical profiles of IBS subtypes and emphasize the need for personalized, multimodal management strategies. Identifying mediators of psychological distress in IBS can guide targeted interventions, improving patient outcomes.

References

1. Lacy, B. E. et al. Bowel Disorders. Gastroenterology (2016) doi:10.1053/j.gastro.2016.02.031.
2. Savarino, E. et al. Functional bowel disorders with diarrhoea: Clinical guidelines of the United European Gastroenterology and European Society for Neurogastroenterology and Motility. United European Gastroenterol J 10, 556–584 (2022).
3. Mearin, F. et al. Clinical Practice Guideline: Irritable bowel syndrome with constipation and functional constipation in the adult. Revista espanola de enfermedades digestivas 108, 332–63 (2016).
4. Baron, R. M. & Kenny, D. A. The moderator-mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations. J Pers Soc Psychol 51, 1173–82 (1986).

Clinical Case Summary

Pseudoachalasia mimics the manometric features of primary achalasia but arises from secondary causes. In lung cancer, it is a rare paraneoplastic manifestation, unrelated to mechanical oesophageal compression. Early recognition and management can improve nutritional status and potentially influence oncological prognosis.
Case report: A 79-year-old woman presented with a three-month history of progressive dysphagia for solids and liquids (Eckardt score 5), accompanied by 7 kg weight loss. Upper endoscopy was unremarkable. A barium swallow showed delayed oesophageal emptying.
High-resolution manometry revealed elevated resting pressure and impaired relaxation at the oesophagogastric junction (OGJ), unresponsive to multiple rapid swallows (Figure 1). Oesophageal contractility was severely impaired, with 90% failed swallows and 70% showing panesophageal pressurization (Figure 2). Two episodes of oesophageal shortening were also noted. Findings were consistent with type II achalasia, but with atypical features.
Given the patient’s smoking history, weight loss, and unusual manometric pattern, thoracic CT was performed, revealing a 13 mm right lower lobe paravertebral nodule (Figure 3) with distal oesophageal wall thickening. Bronchoscopy confirmed lung adenocarcinoma. The patient underwent right lower lobectomy and mediastinal lymphadenectomy.
Four months post-operatively, with dietary modification and nutritional support, the patient reported symptom resolution and weight gain.
Discussion: Pseudoachalasia accounts for ~2% of achalasia cases, often due to malignancy. While most commonly linked to oesophageal or gastric cancer, lung adenocarcinoma is a rare cause. A paraneoplastic mechanism involving myenteric plexus neuronal damage is suspected. Clinicians should consider pseudoachalasia in elderly patients with rapidly progressive dysphagia, significant weight loss, and atypical manometry. Management focuses on oncological treatment and nutritional optimisation.

References

Hirano T, Miyauchi E, Inoue A, Ryotaro Igusa, Chiba S, Sakamoto K, et al. Two cases of pseudo-achalasia with lung cancer: Case report and short literature review. Respiratory Investigation. 2016 Jul 16;54(6):494–9.

Clinical Case Summary

Post-procedural haemorrhage following percutaneous liver biopsy is a rare yet potentially life-threatening complication, with fistulisation of a hepatic haematoma into the gastrointestinal tract being an exceedingly rare event.
A 75-year-old lady with suspected autoimmune liver disease underwent an ultrasound-guided percutaneous liver biopsy with a 16G needle, performed in a single pass and no immediate complications. Two hours later, the patient developed haemorrhagic shock and was transferred to the ICU, where a contrast-enhanced CT scan revealed a 10 × 9 cm hepatic haematoma in the right lobe with active arterial extravasation and haemoperitoneum (Figure 1). Angiography confirmed active bleeding from a segmental branch of the right hepatic artery (Figure 2), which was successfully embolised with microcoils (Figure 3).
Follow-up CT scan 45 days later showed persistent encapsulated haematoma with fistulisation to duodenal bulb (Figure 4). Gastroscopy showed no haemorrhagic content through the fistula (Figure 5). Given the patient's stable condition and reviewed by a multidisciplinary team, surgery was not required. Radiological control after three months, shows near-complete haematoma resolution and fistula closure (Figure 6). Autoimmune hepatitis was confirmed, and immunosuppressive therapy deferred until resolution of the acute complication.
Percutaneous liver biopsy is safe, with ultrasound guidance reducing complication risk. The most common adverse event is pain, in up to 25% of cases. Haemorrhagic complications, including haemoperitoneum, hepatic haematoma, or haemobilia, occur in 0.01–0.5% of cases. Haemobilia, the rarest complication (~0.006%), presents with abdominal pain, jaundice, and melaena. In cases of active bleeding, selective arterial embolisation is preferred. Fistulisation into the gastrointestinal tract is rare and usually associated with large haematomas. Early diagnosis and intervention were key to preventing a fatal outcome in this case.

References

Tian G, Kong D, Jiang T, Li L. Complications After Percutaneous Ultrasound‐Guided Liver Biopsy. Journal of Ultrasound in Medicine. 2020 Jan 30;39(7):1355–65.

Introduction

Gastrointestinal endoscopy is considered a key examination in the setting of anemia workup. However, the yield of esophagogastroduodenoscopy (EGD) and colonoscopy varies depending on the patient's presentation and the type of anemia.

Aims & Methods

The aim of our study was to evaluate the efficiency of EGD and colonoscopy in adult patients with anemia. We retrospectively analysed patients who underwent EGD or colonoscopy for anemia workup in our department between 2018 and 2024. Patients with symptoms suggestive of another cause of anemia were excluded. Additionally, patients who presented with gastrointestinal symptoms and patients with a history of gastrointestinal disease or surgery that could be related to the occurrence of the anemia were also excluded.

Results

A total of 564 patients were included in the study, with a mean age of 72 ±12.8 years. The majority of patients were women (52.8%). 84.9% of the patients underwent EGD, and 49.8% underwent colonoscopy. Overall, 34.8% of patients underwent both examinations. Furthermore, an additional 17.5% were not required to undergo the second examination due to a concrete cause of anemia being found in the initial examination, raising the percentage of patients who completed evaluation to 295 (52.3%). Most of the patients had iron deficiency anemia (IDA) (68.7%). 163 (28.9%) patients had an endoscopic finding that was considered the cause of anemia. EGD yielded significant findings in 119 (24.8%) patients, and colonoscopy in 46 (16.4%) patients. The most prevalent finding of colonoscopy was colon cancer (27 patients), while the most prevalent findings of EGD were peptic ulcer disease (37 patients), stomach cancer (24 patients), and severe atrophic gastritis (18 patients). There was a significant association between the type of anemia and the diagnostic yield of endoscopy, with endoscopic findings being significantly more prevalent in patients with IDA (36.1%) compared to patients without (13.8%) (p < 0.001).

Conclusion

Gastrointestinal endoscopy is the cornerstone examination in patients with unexplained IDA. Conversely, in patients with non-IDA anemia, while endoscopy retains significant diagnostic value, a simultaneous workup for other causes outside the gastrointestinal system is also indicated.

Introduction

Endoscopic submucosal dissection (ESD) is the technique of choice for treating early gastric cancer deemed to have very low risk of lymph node metastasis based on endoscopic evaluation. However, currently, up to 20% of ressected lesions do not meet curative criteria, underlining the importance of patient selection.

Aims & Methods

We aimed to evaluate predictive factors for non curative ressection. We conducted a retrospective cohort study including consecutive gastric epithelial lesions removed by ESD between January of 2005 and June of 2024. Incomplete ESD were excluded. Non curative resection was defined using the high-risk resection criteria from the European Society of Gastrointestinal Endoscopy guidelines. Univariate and multivariate analysis were used to identify predictive factors.

Results

From 990 ESD, 974 were included in the final analysis: median size of lesion 19mm (P25-P75: 15-25), presence of ulceration in 25 (2.8%), deep submucosal invasion in 74 (7.6%), en bloc resection in 944 (96.9%), R0 resection in 901 (92.5%) and non curative resection in 116 (11.9%). In this sample, the following independent predictive factors for non curative resection were identified: location on the superior third of the stomach [adjusted Odds Ratio (aOR) 2.275; IC95% 1.248-4.148], lesion size > 20mm (aOR 4.212; IC95% 2.618-6.775), depressed/ulcerated lesion (aOR 2.394; IC95% 1.328-4.315) or sessile/pedunculated lesion (aOR 4.186; IC95% 2.083-8.411), presence of high-grade dysplasia (aOR 4.372; IC95% 2.139-8.939) or carcinoma (aOR 12.484; IC95% 5.995-25.998) in previous biopsies.

Conclusion

Location, size and morphology of lesion, as well as previous biopsy results are predictive factors for non curative resection, and may assist in decision-making regarding treatment alocation of gastric superficial lesions.

References

Dinis-Ribeiro M, et al. Management of epithelial precancerous conditions and early neoplasia of the stomach (MAPS III): European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter and Microbiota Study Group (EHMSG) and European Society of Pathology (ESP) Guideline update 2025. Endoscopy, 2025 May;57(5):504-554. doi: 10.1055/a-2529-5025.
Vasconcelos AC, et al. Endoscopic Resection of Early Gastric Cancer and Pre-malignant Gastric Lesions. Cancers, 2023 Jun 7;15(12):3084. doi: 10.3390/cancers15123084.