Introduction

Colonoscopy is the gold standard for accurate exploration of the colon. Thus, it must be performed as efficiently as possible with the respect of pre-established quality standards to ensure optimal exploration. The patient's tolerance considerably affects the quality of sedation-free examinations and exposes to a high rate of interruption. Pharmacological sedation can solve this issue, however it can expose to significant adverse events and is not always available.

Aims & Methods

The aim of this study was to evaluate the impact of intraprocedural immersive virtual reality (VR) combining visual and auditory distraction in the improvement of the tolerance and the progress during unsedated colonoscopy. We conducted a prospective controlled study from February to April 2023 including outpatients presenting to the endoscopy unit for unsedated colonoscopy after consent. Patients were randomized into two groups: Group 1: colonoscopy with virtual reality headset. Group 2: control group without intervention.The material used was a virtual reality headset provided with a fully adjustable headband. The video content displayed on the hardware is made of several clips showing nature scenes. The audio content was adapted to allow optimal communication with the patient. We have excluded patients with severe visual and/or auditory impairment, dementia, cognitive impairment and epilepsy. All participants initially completed a form covering health issues and a validated anxiety questionnaire (STAI). After colonoscopy, all patients completed a form with questionnaires assessing per-procedural patient comfort (Gloucester), anxiety (STAI) and pain (EVS). In addition, patients in the intervention group completed a satisfaction questionnaire (NPS: net promoter score) assessing their experiences with the VR headset.

Results

In total, 63 patients were included in the final analysis: intervention group G1 (n=33) and control group G2 (n=30). The mean age was of 57 years. No patient encountered a technical problem with the equipment used and no adverse events occurred during the immersive experience. The two groups were comparable in terms of age, gender, comorbidities, body mass index (BMI) and colonic preparation assessed by the Boston score. A slightly lower time to caecal intubation was noted in the intervention group without significant difference (G1: 19 min vs G2: 26 min, p=0.07). Patients with VR mask expressed lower levels of post-procedural anxiety than those in the control group (Mean STAI G1: 47 vs G2: 53, p<0.01) and a significant decrease in the STAI score compared to pre-endoscopy values (8 points vs 4 points, p<0.01). The per-procedural pain assessed by EVS was significantly lower in the patients using VR (Mean G1: 0.44 vs G2 :1,32, p<0.01). Moreover, endoscopic examination was found to be more comfortable with virtual reality based on the Gloucester scale p <0.01. No patient reported any impediment to communication with medical staff due to the VR mask. Four patients were not satisfied with the resolution of the videos and 8 patients have expressed their preference to choose the content themselves. Patients of the intervention group were greatly satisfied with the VR experience with a mean NPS at 30.

Conclusion

Immersive VR technology is a promising, non-invasive and well-accepted simple tool for improving tolerance by reducing colonoscopy induced pain and anxiety allowing an optimized examination. It can be a useful alternative to conventional sedation if undesired or contraindicated or in health care institutions with a lack of adequate anesthesia facilities.

Clinical Case Summary

Introduction: Locally advanced pancreatic tumors can lead to both biliary and duodenal obstruction by invasion or compression. Quality of life is severely affected if obstruction occurs: jaundice, emesis and pain can become invalidating and patients become too frail for palliative chemotherapy and are sometimes declared unfit even for derivative surgery. Recently, endoscopic techniques under EUS or ERCP guidance are being used to create biliodigestive and enteral anastomoses.
Clinical case: A 75-year-old female was diagnosed with locally advanced pancreatic head adenocarcinoma in January 2024. The tumor was declared unresectable and chemotherapy was initiated. A plastic stent was inserted into the main biliary duct (MBD) to ensure biliary drainage. In May 2024, she presented with cholangitis and emesis. EGD revealed duodenal stenosis and ERCP failed due to tumor infiltration. A combined endoscopic approach was performed: EUS-guided hepatico-gastrostomy (EHG) for biliary drainage and EUS-guided gastro-enterostomy using a lumen-apposing metal stent (LAMS). In July 2024, the plastic stent was removed, and in August 2024, two fully covered 60 x 10 mm SEMS were inserted antegrade through the EHG into the MBD to improve patency. At 11 months post-intervention, the patient returned for routine reassessment, declaring good clinical performance: she remained asymptomatic, with routine blood tests, including bilirubin levels within normal range and with all stents patent and correctly positioned (confirmed radiologically and endoscopically). The patient was able to maintain oral intake and continue chemotherapy. No late adverse events were noted.
Conclusion: This case demonstrates the long-term clinical and technical success of a staged endoscopic triple bypass for the management of complex biliary and duodenal obstruction due to unresectable pancreatic cancer. The approach was minimally invasive, well tolerated and remarkably improved the patient's quality of life.

References

1. Adler, Douglas G MD; Baron, Todd H MD, FACP. Endoscopic Palliation of Malignant Gastric Outlet Obstruction Using Self-Expanding Metal Stents: Experience in 36 Patients. American Journal of Gastroenterology 97(1):p 72-78, January 2002. | DOI: 10.1111/j.1572-0241.2002.05423.x
2. Giovannini, Marc. (2019). EUS-guided hepaticogastrostomy. Endoscopic Ultrasound. 8. 35. 10.4103/eus.eus_47_19.
3. Dumonceau, Jean-Marc & Tringali, Andrea & Blero, Daniel & Devière, J & Laugiers, R & Heresbach, D & Costamagna, Guido. (2012). Biliary stenting: Indications, choice of stents and results: European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline. Endoscopy. 44. 277-98. 10.1055/s-0031-1291633.
4. Van Der Merwe, S. W., Van Wanrooij, R. L., Bronswijk, M., Everett, S., Lakhtakia, S., Rimbas, M., ... & Van Hooft, J. E. (2022). Therapeutic endoscopic ultrasound: European society of gastrointestinal endoscopy (ESGE) guideline. Endoscopy, 54(02), 185-205. 10.1055/a-1717-1391

Clinical Case Summary

Introduction: We present the case of a 30-year-old patient with severe Crohn's disease (Montreal classification A2, L3, B3). The patient had been on infliximab therapy since March 2022 with partial clinical benefit and residual endoscopic and histologic disease activity (SES-CD 6, January 2023).
Case report: In October 2023 on physical examination, the patient showed the appearance of an erythematous and painful nodule at the level of the middle third of the posterior surface of the leg. After one week, the lesion appeared ulcerated, with a necrotic base and a violaceous, raised peripheral rim.(figure 1) After dermatologic evaluation, the diagnosis of pyoderma gangrenosum was posed. This was the pustular subtype, the variant of pyoderma most related to inflammatory bowel disease. The patient started corticosteroid therapy by oral somministration and IFX therapy was discontinued. At follow-up after twenty days from the start of therapy, the patient showed a slight reduction of the lesion in question, however, in the days to follow a similar lesion appeared at the level of the left gluteal region.(figure 2) Therefore, in consultation with the dermatology specialist, it was planned to tapering corticosteroid therapy until it was completely discontinued and to start the patient on off-label treatment with Upadacitinib at dosage of 45 mg in daily single administration for twelve weeks. At week 12, both lesions showed a marked improvement.(figure 3) In addition, the patient reported clinical benefit about bowel activity. Therefore, it was decided to continue Upadacitinib with a dosage of 30 mg 1 cp/day. At week 20 of therapy, lesion resolution and healing were noted.(figure 4)
Conclusions: Our cases support the efficacy of Upadacitinib for the treatment of complicated Crohn's disease with the presence of extraintestinal manifestations. and up to our knowledge this is the first report of a successful treatment with Upadacitinib in a patient with concomitant PG and CD.

References

Figure 1: lesion ulcerated,at the level of the middle third of the posterior surface of the leg , with a necrotic base and a violaceous, raised peripheral rim.
Figure 2: lesion at the level of the left gluteal region.
Figure 3: At week 12, both lesions showed important degree of improvement
Figure 4: lesion resolution

Clinical Case Summary

A 23-year-old female presented with epigastric pain, jaundice, and elevated liver enzymes. Imaging confirmed a mildly dilated common bile duct (CBD) with multiple filling defects. ERCP revealed a normal ampulla and a half-sphincterotomy was performed with three stones retrieved via balloon trawl. The procedure was uneventful, and she was discharged the same day.
Three days later, she re-presented with dizziness, melaena, and a haemoglobin drop from 127 g/L to 85 g/L. Gastroscopy demonstrated active oozing from the sphincterotomy site, managed successfully with placement of a fully covered metal stent (FCMS). She remained stable and was discharged with outpatient follow-up.
Three weeks later, she re-presented with partial stent blockage and underwent repeat ERCP for stent removal and duct clearance. Within 24 hours, she developed acute left shoulder tip and chest pain. Cardiac investigations were negative. CT imaging demonstrated a large haemoperitoneum and a bulging splenic haematoma without active bleeding, confirmed on a diagnostic laparoscopy .
She was managed conservatively in intensive care and follow up imaging confirmed complete resolution of the haematoma.
This case illustrates splenic haematoma as a rare yet significant complication of ERCP, with only a handful of cases described in the literature. Proposed mechanisms involve shear forces transmitted via the splenogastric ligament, typically in patients with known risk factors such as intra-abdominal adhesions, previous surgery, chronic pancreatitis, or cirrhosis. However, this case highlights its occurrence in a young, healthy patient with no risk factors, suggesting procedural technique or anatomical variation to be a potential trigger for injury. Symptoms such as shoulder or upper quadrant pain following ERCP should prompt consideration of splenic injury. Early recognition is key, as many cases resolve with conservative management but may carry a risk of life-threatening bleeding if unrecognised.

References

MRCP Image Demonstrating CBD Filling Defects
Coronal MRCP showing a mildly dilated common bile duct with multiple signal voids consistent with choledocholithiasis.
ERCP Image Showing Duct Clearance
Fluoroscopic image during ERCP showing balloon trawl and retrieval of multiple CBD stones following half-sphincterotomy.
Blood Results Demonstrating Haemoglobin Drop
Laboratory panel showing haemoglobin decline from 127 g/L to 85 g/L following gastrointestinal bleeding.
Gastroscopy Image Demonstrating Oozing and FCMS Placement
Endoscopic image showing active oozing at the sphincterotomy site and successful placement of a fully covered metal stent.
CT Image of Splenic Haematoma
Axial CT abdomen showing extensive haemoperitoneum and a bulging splenic haematoma in the left upper quadrant.
Follow-up CT Confirming Resolution
Interval CT imaging showing complete resolution of the previously identified splenic haematoma.

Introduction

Aspiration Pneumonia is a well described complication of upper digestive endoscopy. However, limited data are available on incidence, risk factors and clinical consequences of post- Endoscopic retrograde cholangiopancreatography (ERCP) aspiration pneumonia (pEP).

Aims & Methods

All consecutive ERCPs performed under anesthesiologist-administered sedation at the Endoscopy Unit of the University of Verona between April 1st 2022 and August 31st 2024 were retrospectively evaluated. Demographical, clinical and endoscopic data were collected.

Results

One-thousand-one-hundred-forty consecutive ERCPs were included. Main indication was malignant biliary stricture and patient’s mean age was 68±13.9 years. Overall incidence of pEP was 2.7%. American Society of Anesthesiologists (ASA) score, presence of active cholangitis before ERCP and performance of endoscopic ultrasound (EUS) and ERCP in the same sedation session were significantly associated to higher risk of pEP at both univariable and multivariable analysis. pEP was an independent risk factor for post-ERCP 30-days-mortality and for prolonged hospital stay.

Conclusion

pEP is a relatively frequent adverse event after ERCP. In patent with high ASA score, active cholangitis and scheduled EUS and ERCP in the same sedation session, preventive medical and/or anesthesiological strategies might be considered. Additional prospective studies are needed to confirm these data.

References

Incidence rates of post-ERCP complications: a systematic survey of prospective studies. Complications of ERCP: a prospective study.
ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline.
Unrecognised aspiration pneumonitis during enteroscopy: two case report.
Efficecay and safety of therapeutic endoscopic retrograde cholangiopancreatography in patients with native papillae with a performance status score of 3 or 4: a single-center retrospective study.
A prospective assessment of sedation-related adverse events and patient and endoscopist satisfaction in ERCP with anesthesiologist-administred sedation.
Increased ERCP-related adverse event from premature urgent ERCP following symptom onset in acute biliary pancreatitis with cholangitis.
Acute sedation-associated complications in GI endoscopy (ProSed 2 Study): results from the prospective multicentre electronic registry of sedation-associated complications.
Deep sedation without intubation for ERCP is appropriate in healthier, non-obese patients.
Comparative efficacy and safety of anesthetic and sedative regimens for endoscopic retrograde cholangiopancreatography: a network meta-analysis.
International consensus recommendations for difficult biliary access.
Intraprocedural quality in endosocpic retrograde cholangiopancreatography: e meta-analysis.
Criteria for difficult biliary cannulation: start to count.
Safety and efficacy of therapeutic endoscopic retrograde cholangiopancreatography for patients over 90 years of age.
Risk factors for post-endoscopic retrograde cholangiopancreatography complications in very elderly patients aged 90 years or older-no additional risk.

Disclosure

I have no conflict of interest

Introduction

Endoscopic papillectomy (EP) for duodenal ampullary tumors is primarily performed for lesions confined to the papilla, particularly adenomatous changes. However, early complications such as bleeding (0-21.6%), pancreatitis (0-23.1%), and perforation (0-8.3%) occur at relatively high rates. Post-EP bleeding, due to anatomical characteristics of the ampulla of Vater, can be challenging to manage and may worsen, making it critical to identify factors associated with this complication to reduce its frequency.

Aims & Methods

The study aimed to investigate the factors associated with post-endoscopic papillectomy bleeding in patients with ampullary tumors. This study included 39 patients (39 lesions), excluding residual and accessory ampullary lesions, who underwent EP at our institution between March 2011 and October 2024. We evaluated univariate analysis and SHAP values based on tree-based models for several factors related to post-EP bleeding. Hyperparameters of each model were optimized by optuna, and those models were trained with the Python package scikit-learn (version 1.3.0).

Results

The cohort included 1 adenocarcinoma, 32 adenomas, 1 neuroendocrine neoplasm, and 5 cases of ampullary inflammation, with a mean age of 66.7 years (23 males, 16 females). Patient factors included: The American Society of Anesthesiologists (ASA) Physical Status Classification I/II/III in 5/21/13 participants, median Charlson Comorbidity Index (CCI) of 1 (range 0-7), 15 cases with a history of alcohol consumption, median Brinkman Index of 100 (range 0-1680), median total bilirubin of 0.7 mg/dL (range 0.2-2.1), median serum amylase of 80 IU/L (range 36-296), median platelet count of 198,000/μL (range 113,000-494,000), median PT-INR of 0.98 (range 0.86-1.14), median APTT of 28.7 seconds (range 23.0-39.4), median CEA of 1.9 ng/mL (range 0.3-12.8), and median CA19-9 of 7.7 U/mL (range 0.8-76.4). Antithrombotic agents were used in 4 participants (1 on low-dose aspirin, 1 on clopidogrel, and 2 on direct oral anticoagulants), and periampullary diverticula were observed in 3 cases. Median tumor size was 10.3 mm (range 2.0-45.0). Procedural factors included a median total procedure time of 56 minutes (range 23-230), with 36 cases receiving endoscopic biliary stenting and 38 cases receiving endoscopic pancreatic duct stenting. The electrosurgical units ICC200/VIO300D/VIO3 were used in 9/19/11 cases, respectively. Protease inhibitors were used in 9 participants, NSAID suppositories (25mg/50mg) in 5/24 cases, and local hemostatic measures included epinephrine spray in 8 cases, thrombin spray in 8 cases, and hemostatic peptide solutions in 5 cases. Clipping for ulcer after resection was performed in 33 cases. Post-EP bleeding within 30 days occurred in 12 cases (30.8%), including 9 moderate and 3 severe cases. Univariate analysis revealed that a history of alcohol consumption was significantly associated with post-EP bleeding (Odds ratio [OR] 2.33, 1.14-4.79, P = 0.02). Feature importance was evaluated using the mean absolute SHAP values across all participants. In the Random Forest model, the top contributing features were CA19-9 (mean |SHAP| = 0.026), CCI (mean |SHAP| = 0.024), and a history of alcohol consumption (mean |SHAP| = 0.023). In contrast, the XGBoost model identified tumor size (mean |SHAP| = 0.315), a history of alcohol consumption (mean |SHAP| = 0.244), and platelet count (mean |SHAP| = 0.198) as the most important features.

Conclusion

In our cohort, a history of alcohol consumption is a robust factor associated with post-endoscopic papillectomy bleeding.

Introduction

Inflammatory Bowel Diseases (IBD) patients are associated to a higher risk of developing colonic dysplasia and colorectal cancer due to long-standing colonic inflammation and immunosuppressant therapies. They seem to have also a higher risk of developing extra-intestinal malignancies, such as cholangiocarcinoma, skin cancer, and others. Different studies have been conducted to assess whether a correlation exists between IBD, medical treatments and cancers, but the results are controversial.

Aims & Methods

Our study aimed to evaluate the risk factors of malignancies in our IBD patients, particularly considering the medication history.
In this single-center retrospective study, IBD patients with a history of at least one malignancy post-IBD diagnosis followed at the Gastroenterology Unit of Azienda Ospedale Università Padova were enrolled (cases). Demographics and clinical data, including medication information, were collected before and at the time of malignancy diagnosis. A group of IBD patients, matched by sex and age, without a malignancy history were also included (controls), considering the medications taken before and at the time of the last visit for comparison.

Results

Among 2213 IBD patients followed at our center (1212 males, 1040 CD, and 1173 UC), 153 cases (80 UC and 73 CD, 46.4% males, mean age at diagnosis: 38.4±14.7) and 50 sex and matched controls were included (30 UC and 20 CD, 52% males, mean age at diagnosis: 38.9±0.8). Twelve patients had two malignancies, and 2 had three. For the scope of our study, we considered only the first tumor. Results are shown in the Table 1. The mean time from IBD diagnosis to the first tumor was 15 years (SD 10.5). Considering malignancies, the most frequent in our population were breast cancer (27/1001 females, 2.7%), colorectal cancer (23/2213, 1%), melanoma (24/2213, 1.1%), and non-melanoma skin cancer (15/2213, 0.7%). Patients with colon cancer were younger at the time of IBD diagnosis (31.0±15.8 vs. 38.9±0.8), while patients with prostate and urinary cancer (11/2213, 0.5%) were older compared to controls (49.6±13.7 vs. 38.9±0.8). A lower percentage of patients with colon (13%), breast (4%), and prostate cancers (9.1%) had taken biological therapy before cancer occurrence, as compared to controls (44%, p<0.01). Finally, we observed a significantly higher number of melanoma and breast cancer patients taking azathioprine (AZA) at the time of cancer diagnosis for more than 4 years. No difference in terms of duration of AZA and biological therapies before cancer diagnosis was observed.

Table 1: Type and frequency of Malignancies and characteristics of the patients

Conclusion

Our study found that biological therapy was not associated to malignancies, while azathioprine use was associated with breast and melanoma cancers. A younger age at diagnosis was associated with colon cancer, while an older age with prostate and urinary cancers.