Introduction

Climate change is a major challenge to our future generations and environment, and limiting its effects is necessary in every aspect of our daily lives. Endoscopy units are one of the most resource-intensive hospital departments, producing large amounts of contaminated waste, mostly disposed of by incineration, generating large quantities of CO₂. The environmental impact of endoscopy needs to be better investigated as current ESGE/ ESGENA guidelines propose reducing waste by first creating awareness via implementing audits to assess waste production¹. We sought to investigate the feasibility of an audit procedure assessing waste production and mechanisms of disposal to understand where to reduce, reuse or recycle the waste.

Aims & Methods

During one working week in March 2023, we performed a structured waste audit in collaboration with the department for environmental sustainability in the endoscopy department of the university hospital of Basel, a tertiary referral center in northwestern Switzerland, performing >6000 endoscopic procedures per year. Waste was collected separately in patient-specific bags for each procedure, from the preparation of the patient to discharge by two investigators. The use of sharps and reusable equipment (e.g., tubing, etc.) was included in the calculation of the waste generated per procedure.

Results

During the study period,the normal running of the endoscopy unit was not disrupted. Waste produced by 75 examinations was analyzed. Median waste production was 910 g/ Gastroscopy, 1060g/ Colonoscopy, 1110g/ Gastro-and Colonoscopy, 1240 g/ Sigmoidoscopy and 1823 g/ ERCP or EUS. This adds up to 26 kg of waste per day or 52 t of CO₂ generated by incineration per year in our endoscopy unit.

Conclusion

A structured waste audit can easily be incorporated into the daily practice of an endoscopy unit without impacting patient care and using few resources. Creating awareness of waste generation and composition is a crucial first step toward creating sustainable endoscopy practice. The amount of C0₂ generated by our endoscopy unit in a year equals driving eight times around the world. Gastroscopy and colonoscopy should be combined in one procedure when possible.

References

1 Santiago E, Dinis-Ribeiro, Pohl H et al. Endoscopy. 2022; 54

Introduction

Response rates to the Low FODMAP Diet (LFD) in IBS vary and predictors of benefit remain poorly defined. While several studies from Western populations have identified microbial signatures linked to response, data from Asian cohorts remain limited.

Aims & Methods

This study aims to identify microbial predictors and longitudinal microbiome shifts in Asian IBS-D patients consuming a LFD. We recruited 20 adult Asian patients with IBS-D diagnosed according to the ROME-IV criteria. All subjects received LFD dietary advice from a dietitian at initiation and were followed-up for a total of 28-days. Clinical response was assessed by a ≥50-point improvement in the IBS Symptom Severity Score (IBS-SSS) from Day 0 (baseline) as compared to follow-up at Day 28. Stool samples were collected at baseline, Day 14, and Day 28. Microbial DNA was extracted using bead-beating and Qiagen PowerFecal kits, and the V3–V4 region of the 16S rRNA gene was amplified and sequenced on the Illumina MiSeq platform. Bioinformatic processing included denoising with DADA2, taxonomic assignment using the SILVA 138 database, and rarefaction to even sequencing depth. Microbiome metrics included alpha diversity (Shannon and Simpson), beta diversity (Bray-Curtis PCoA with PERMANOVA), and differential abundance testing with DESeq2.

Results

By Day 28, 11 of 20 patients (55%) achieved clinical response, with a median IBS-SSS reduction of 172 points (IQR: 88–248), compared to 24 points in non-responders (IQR: −11 to 55; p=0.003). Alpha diversity was not significantly different between groups, but responders exhibited a trend toward higher Shannon and Simpson diversity at baseline. Beta diversity analysis using Bray-Curtis dissimilarity revealed partial clustering by responder status (PERMANOVA p=0.06), and PCoA plots showed individual-specific shifts in community structure across time, indicating that the LFD induces personalized microbiome trajectories.
At baseline, responders had significantly higher relative abundances of butyrate-producing and anti-inflammatory genera, including Ruminococcus, Blautia, Eubacterium siraeum, and Bifidobacterium bifidum (adjusted p<0.05). These findings are consistent with prior reports, including Bennet et al. (2018) and Vervier et al. (2022), where such taxa were part of a “health-like” IBS-P (pathogen-enriched) to IBS-H (health-like) axis. The enrichment of Blautia and Ruminococcus is particularly noteworthy as these are established butyrate producers involved in maintaining colonic barrier function and reducing visceral hypersensitivity. By Day 28, differential abundance analysis revealed that responders exhibited increases in Ruminococcus bicirculans, Parabacteroides gordonii, and Weissella cibaria. In contrast, non-responders showed persistence or increases in taxa such as Tyzzerella and Olsenella, which have been associated with inflammation or IBS severity in prior studies (Chuah et al., 2024).

Conclusion

This study provides novel microbiome insights from an underrepresented Asian IBS population consuming a LFD. Despite dietary and baseline microbiota differences from Western populations, we observed remarkably consistent microbiome predictors of response, including higher baseline levels of butyrate-producing taxa and favorable microbial restructuring during the intervention. These results reinforce the reproducibility and functional relevance of microbiome predictors in IBS dietary therapy, and support microbiome profiling as a potential tool for personalized dietary guidance across a diverse global population.

References

Bennet SMP et al. Multivariate modelling of faecal bacterial profiles of patients with IBS predicts responsiveness to a diet low in FODMAPs. Gut. 2018 May;67(5):872-881.
Vervier K et al. Two microbiota subtypes identified in irritable bowel syndrome with distinct responses to the low FODMAP diet. Gut. 2022 Sep;71(9):1821-1830.
Chuah KH, Mahadeva S. Can we predict who will respond to a low-FODMAP diet in irritable bowel syndrome? J Gastroenterol Hepatol. 2024 Feb;39(2):217-218. ​

Introduction

Recently, a subcutaneous formulation of biosimilar infliximab (CT-P13) (SC-IFX) has been approved for inflammatory bowel disease (IBD). The aims of this study were to evaluate efficacy, safety, pharmacokinetics and patient experience following a switching to SC-IFX in patients who are in clinical remission on IV-IFX maintenance treatment.

Aims & Methods

Multicentre, descriptive, and observational study including Crohn’s disease (CD) and ulcerative colitis (UC) patients who were going to be changed from IV-IFX to SC-IFX on the ENEIDA registry (a large, prospectively maintained database of the Spanish Working Group in IBD–GETECCU). All patients were on clinical and biological remission at least 24 weeks before changing. Demographic and disease data, clinical activity (Harvey-Bradshaw index for CD and mayo index for UC), analytical data (C reactive protein (CRP) and fecal calprotectin (FC), as well as trough levels were collected at baseline, at 12 and 24 weeks.

Results

One hundred and fifty-five patients were included: 54 UC (35%) and 91 (65%) CD; 44% women and 56% men; age 45.5 years (32-55). IV-IFX was mainly administered due to active disease (72%) and perianal disease (7%) and during 32 months [range 14-56]. Pre-switch, 78 (50.3%) were on 8-weekly dosing of IV-IFX, 77 (49.7%) were with intensification dose and the half (50.3%) were on concomitant immunomodulatory therapy. SC-IFX was mainly switching by COVID-19 pandemic (60%), to increase through levels (15%) or patient request (25%). The majority of patients (140, 90%) remained with standard dose, 8 (5%) required dose intensification (120 mg weekly in 4 and 240 mg every 2 weeks in 4) and 7 (4.5%) had successful de-escalation (120 mg every 3 weeks in 4 and 120 mg every 4 weeks in 3). Clinical indices, CRP levels and FC remained unchanged. Median SC-IFX levels significantly increased from baseline of 4.5 μg/dl [range 2.6-9.2] to 14 μg/dl [range 9.5-16.2] at week 12 and 13.2 μg/dl [range 10.4-19.7] at week 24. No factors (immunossupresor, body mass index, disease location) were associated with the increase of IFX trough levels. During 24 weeks of follow-up, 16 of the 78 patients (20.5%) stopped immunosuppressant treatment. The adverse events were recorded in 9 patients (5.8%), 4 (2.6%) were hospitalized and 4 (2.6%) had surgery (one of them for perianal disease). Nine patients (5.8%) stopped SC-IFX (1 primary failure, 2 loss of response, 4 adverse events, 1 voluntarily, and 1 surgery).

Conclusion

The switch from IV to SC IFX maintains clinical remission safely in IBD patients, offers higher drug levels and a good patient acceptance. However, the significance of higher drug levels with SC-IFX requires further exploration.

Introduction

Etrasimod is an investigational, oral, once-daily, selective sphingosine 1‑phosphate (S1P)_1,4,5 receptor modulator in development for the treatment of moderately to severely active ulcerative colitis (UC). In ELEVATE UC 52 (NCT03945188), etrasimod was superior to placebo (PBO) in achieving Week (Wk) 52 corticosteroid (CS)-free clinical remission (CR).¹

Aims & Methods

This post hoc analysis reports CS-free efficacy and safety in patients (pts) on baseline (BL) CS. Pts were randomised 2:1 to once-daily etrasimod 2 mg or PBO using a treat-through design (12-wk induction and 40-wk maintenance period). At entry, pts could receive concomitant CS (prednisone [≤ 20 mg/day], budesonide [≤ 9 mg/day] or equivalent) if on a stable dose ≥ 4 wks immediately before screening endoscopy; from Wk 12, CS tapering was recommended. CS-free was defined as withdrawal of CS ≥ 12 wks prior to assessment timepoint. CS-free outcomes assessed were CS-free CR at Wk 52, CS-free endoscopic improvement (EI) at Wk 52, and CR at Wk 12 + CS-free CR at Wk 52. From Wk 12, 4-wk CS‑free symptomatic remission (SR; 4 wk in contrast to ≥ 12-wks CS free) was analysed at each visit. Logistic regressions examined associations with CS-free efficacy at Wk 52. Safety was assessed.

Results

At BL, 32.2% (93/289) and 29.2% (42/144) of etrasimod and PBO pts received CS; of these, significantly more etrasimod vs PBO pts achieved CS-free CR at Wk 52, CS-free EI at Wk 52 and CR at Wk 12 + CS-free CR at Wk 52 (all p<0.05; Table). At Wks 40–52, there were significant differences (16.6–26.6%; p<0.05) in 4-wk CS-free SR between etrasimod and PBO. In this subpopulation, being biologic/Janus kinase inhibitor-naïve was not a significant predictor of 12-wk CS-free CR at Wk 52 (odds ratio [OR]: 3.61; 95% confidence interval [CI] 0.91, 14.39; p=0.07); age, per 10-year increase, was significantly associated (OR: 1.51; 95% CI 1.03, 2.22; p=0.04). Etrasimod vs PBO pts with concomitant CS at BL experienced slightly more adverse events (AEs; not exposure adjusted) (71.0% [66/93] vs 61.9% [26/42]) but fewer serious AEs (6.5% [6/93] vs 14.3% [6/42]), including serious infections (0% [0/93] vs 7.1% [3/42]).

Conclusion

More etrasimod vs PBO pts who received CS at BL met CS‑free efficacy endpoints. Four-wk CS-free SR with etrasimod was superior to PBO from Wk 40. Concomitant CS use at BL had no notable negative effect on the safety of etrasimod, consistent with the overall ELEVATE UC 52 population.¹

References

1. Sandborn W et al. Lancet 2023: Epub ahead of print.

Disclosure

BES: grants/research: Arena, Janssen; speaker: BMS, Janssen, Lilly, Pfizer, Takeda; consultancy/advisory board: AbbVie, Alimentiv, Amgen, Arena, AstraZeneca, Boehringer-Ingelheim, BMS, Celltrion, Fresenius Kabi, Genentech, GSK, Janssen, Lilly, Merck, Pfizer, Prometheus Biosciences, Sun Pharma Global, Takeda Pharmaceuticals International, Teva Branded Pharmaceutical Products R&D; stock: Ventyx Biosciences; non-financial support: Janssen, Lilly, Pfizer, Takeda.
YL: speaker: Pfizer Inc, Takeda, Abbvie, Jannsen; Consultancy, Advisory Committee/Board Member: Pfizer Inc, BMS, Takeda, Abbvie, Amgen BioJamp, Lilly.
DTR: grant support: Takeda, Helmsley Charitable Trust, GastroIntestinal Research Foundation; consultancy fees/is a member of advisory boards: AbbVie, AltruBio, ASLAN Pharmaceuticals, Athos Therapeutics, Bellatrix Pharmaceuticals, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Chronicles, Syneos, ClostraBio, Connect Biopharma, EcoR1, Genentech/Roche, Gilead Sciences, Iterative Health, Janssen Pharmaceuticals, Kaleido Biosciences, Eli Lilly, Pfizer Inc, Prometheus, Reistone, Seres Therapeutics, Takeda, Target RWE, Trellus Health; is on the Board of Trustees for Crohn’s & Colitis Foundation and Cornerstones Health, Inc; holds stock options in Alike Health, AltruBio, Datos Health and Iterative Health.
KBG: research support: Celltrion, Galapagos, Pfizer Inc; speaker honoraria and/or consulting fees: AbbVie, Celltrion, Ferring Pharmaceuticals, Immunic Therapeutics, Janssen, Novartis, Pfizer Inc, Samsung Bioepis, Takeda, Tillotts.
JP: personal: AbbVie, Arena, Athos, Atomwise, Boehringer Ingelheim, Celgene, Celltrion, Ferring Pharmaceuticals, Galapagos, Genentech/Roche, GSK, Immunic, Janssen, Mirum, Morphic, Nestlé, Origo, Pandion, Pfizer Inc, Progenity, Revolo, Takeda, Theravance Biopharma and Wassermann; grant support: AbbVie, Pfizer Inc.
MG: employee & shareholder of Pfizer AG.
WW, KS, JCW, CCS: employees & shareholders of Pfizer Inc.
KW: employee & shareholder of Pfizer Canada Inc.
SS: speaker: AbbVie, Arena, Biogen, Bristol-Myers Squibb, Celgene, Celltrion, Dr. Falk Pharma, Fresenius, Janssen, MSD, Pfizer Inc, Takeda; consultancy/advisory: AbbVie, Arena, Biogen, Bristol-Myers Squibb, Celgene, Celltrion, Dr. Falk Pharma, Fresenius, Gilead Sciences, IMAB, Janssen, MSD, Mylan, Pfizer Inc, Protagonist, Provention Bio, Takeda, Theravance.

Clinical Case Summary

A 74-year-old male presented in November 2022 with abdominal distension, mild anemia, recurrent oral aphthae, and alternating diarrhea and constipation. A 2021 colonoscopy was normal. Enterotomography revealed two segments of irregular parietal thickening in the distal ileum. Repeated colonoscopy confirmed thickened distal ileum with ulcerations. Biopsies identified chronic active ileitis without granuloma; stains for fungi and acid-fast bacillus were negative.
A presumptive diagnosis of Crohn’s disease was made, and azathioprine and prednisone were initiated. In March 2023, the patient developed ileal perforation requiring urgent right ileocolectomy with ileostomy. On follow-up endoscopies, gastric ulcer with unremarkable histopathology and perianastomotic Rutgeerts i2 recurrence were identified, and infliximab was initiated.
In January 2024, patient complained of intense cervical odynophagia and new genital and oral ulcers. Endoscopy showed an ulcer on the aryepiglottic fold, while biopsy of the genital lesion revealed erosive chronic inflammation with fibrinoleukocytic exudate and positive C3c immunofluorescence.
In March 2024, methotrexate and colchicine were initiated for suspected Behçet’s disease, with incomplete improvement of oral ulcers, and a trial of thalidomide 100mg qd was performed with adequate clinical control. A December 2024 endoscopy was normal, and colonoscopy showed only minimal erosions in the blind loop. Patient remained clinically well, with clinical remission.
This case highlights an uncommon presentation of Behçet’s disease (BD). While gastrointestinal involvement is well-documented in BD, the onset in advanced age, as well as initial diagnosis as Crohn’s disease, posed a diagnostic dilemma. The development of oral, genital, and laryngeal ulcers, along with positive C3c and clinical response to colchicine supported the diagnosis. Differentiating BD from Crohn’s disease is critical due to implications for management and prognosis.

References

Image 1: endoscopic image of ileal ulcerations.
Image 2: endoscopic image of the ulceration on the aryepiglottic fold
Image 3: image of tongue ulceration

Introduction

Measurement of the size of colorectal polyps during colonoscopy is carried out mainly by visual estimation. We developed a novel polyp size measurement system (Poseidon) based on artificial intelligence that uses the auxiliary water jet as a measurement reference.

Aims & Methods

Visual estimation, biopsy forceps measurement, and Poseidon were compared using a CT colonography-based silicon colon model with 28 polyps of known size. Four experienced endoscopists estimated polyp size visually and with biopsy forceps. The endoscopists took images of each polyp with the water jet in its proximity. These images were then analyzed by Poseidon to measure the size of the polyp.
Additionally, the Poseidon measurements were compared to visual size estimates of 29 colorectal polyps examined during clinical routine.

Results

In the silicone colon model, the visual estimation had the largest median percent error (PE) of 25.2% (interquartile range (IQR: Q1, Q3): 11.8, 43.1), followed by the biopsy forceps measurements with a median PE of 20% (IQR: 9.1, 34.3). Poseidon had a significantly lower median PE of 7.4% (IQR: 3, 15.7, p<0.001) than the other two methods.
At routine colonoscopies, Poseidon had a significantly lower median PE (7.7%; IQR: 2.7, 12.6) than the visual estimation (22.1%; IQR: 12.4, 34.1, p<0.001).

Conclusion

In this work, we present a novel method to measure the size of colorectal polyps, which has a significantly higher accuracy than other common polyp sizing methods.