Clinical Case Summary

Intra-ampullary papillary tubular neoplasms (IAPNs) are rare neoplastic intraepithelial lesions that occur within the ampulla. Given their well-documented malignant potential, early recognition and intervention are paramount to prevent malignant transformation. We present a case of IAPN successfully managed via endoscopic papillectomy.
A 58-year-old male was incidentally found to have a bulky-appearing ampulla of vater during esophagogastroduodenoscopy as part of routine health screening. Endoscopic ultrasonography revealed a 20-mm hyperechoic lesion at the ampulla, with histopathological evaluation demonstrating low-grade dysplasia (indeterminate for neoplasia). Laboratory investigations, including hematological parameters, biochemical profiles, and tumor markers, were within normal limits. Contrast-enhanced abdominal CT demonstrated a well-defined, homogeneously enhancing 20-mm lesion at the ampullary region without biliary/pancreatic duct dilation.
Endoscopic papillectomy was performed using a duodenoscope with snare. Prophylactic stents were placed in both the biliary and pancreatic ducts to ensure adequate drainage. Any intraprocedural bleeding was promptly controlled with hemoclip application. Histopathological analysis confirmed high-grade IAPN, characterized by a polypoid tumor with closely packed tubular glands lined by pseudostratified columnar epithelium showing loss of polarity and moderate nuclear atypia (Ki-67 index: 50%). The postoperative course was uncomplicated, with discharge achieved on the sixth postoperative day. At six-month follow-up evaluation, surveillance endoscopic ultrasonography showed no evidence of recurrence.
IAPN represents a distinct neoplastic ampullary entity within the spectrum of ampullary tumors. While endoscopic resection demonstrates therapeutic efficacy, its implementation requires advanced endoscopic expertise in specialized centers.

References

Endoscopic ultrasonography revealed a 20-mm hyperechoic lesion at the ampulla
Endoscopic papillectomy was performed using a duodenoscope with snare. Prophylactic stents were placed in both the biliary and pancreatic ducts to ensure adequate drainage. Any intraprocedural bleeding was promptly controlled with hemoclip application.
Histopathological analysis confirmed high-grade IAPN, characterized by a polypoid tumor with closely packed tubular glands lined by pseudostratified columnar epithelium showing loss of polarity and moderate nuclear atypia (Ki-67 index: 50%).

Clinical Case Summary

Introduction: Dieulafoy lesions account for less than 2% of gastrointestinal bleeds, and only 20% of these occur outside the stomach. We present a rare case of a bleeding ampullary Dieulafoy lesion with technical difficulties in management, starting with a standard forward-viewing gastroscope, subsequent use of a side-viewing duodenoscope, and eventually endoscopic retrograde cholangiopancreatography (ERCP) and stenting to allow for safe haemostasis with argon plasma coagulation (APC).
Case report: A 56-year-old male was admitted with pneumonia and fluid overload in the context of end-stage renal disease from poorly controlled diabetes mellitus and hypertensive nephrosclerosis on regular haemodialysis. He was on dual anti-platelet therapy with aspirin and ticagrelor for a recent cardiac stent.
Five days into his admission he was noted to have melena with a haemoglobin drop from 87 g/L to 56 g/L, with a urea rise of 23.9 mmol/L from a baseline of 11.0 mmol/L.
Subsequent gastroscopy revealed active bleeding from the major ampulla without any underlying ulcer or tumour, superior to the biliary orifice, consistent with an ampullary Dieulafoy lesion. The duodenoscope was then introduced for a better view and access to the major ampulla. APC was attempted at 0.8 L/min at 30 Watts due to the size and location, but haemostasis was unsuccessful.
The decision was made to proceed to ERCP and biliary stenting to prevent complications from heat injury to the bile duct and possible pancreatitis. A 7 Fr by 4 cm double pigtail biliary plastic stent was placed into the common bile duct. APC was re-applied at 0.8 L/min at 30 Watts at the bleeding spot with successful haemostasis.
Discussion: This case report aims to highlight the rare occurrence of duodenal ampullary Dieulafoy lesions and the need for prompt recognition and use of resources such as side-view duodenoscopy and ERCP for safe therapeutic management.

Disclosure

None

Introduction

Endoscopic papillectomy(EP)is a viable treatment option for ampullary lesions(AL).While many studies have reported low morbidity and acceptable outcomes, early attempts to pool data from these initial experiences have produced conflicting conclusions regarding key technical aspects. To address these uncertainties, we conducted a systematic review and pooled analysis to evaluate the safety and efficacy of EP for AL,identifying factors that may influence outcomes.

Aims & Methods

Electronic databases(Medline, Scopus and EMBASE)were searched up to September 2024. Studies that included patients with endoscopically resected AL were eligible. Efficacy and safety outcomes were pooled by means of a random-effects model to obtain a proportion with a 95% confidence interval(CI). Univariable meta-regression analyses were conducted to explore potential factors affecting outcomes.

Results

A total of 60 studies(4,859 lesions)published between 2002 and 2024 were analyzed. Complete resection was achieved in 86.2%of cases, though intraductal involvement limited success. The recurrence rate was 18.6%, however, the majority(89.3%)of patients were managed endoscopically without surgery. The pooled adverse event(AE)rate was 30.0%, with bleeding(12.2%)and post-procedural pancreatitis(11.1%)being the most common complications. Prophylactic stenting reduced pancreatitis risk, while intraductal involvement increased perforation risk.Adjunctive treatments for intraductal involvement were associated with an increased risk of papillary stricture.

Conclusion

Endoscopic papillectomy is a safe and effective treatment for ampullary lesions. However, lesions with intraductal extension pose a higher risk of incomplete resection and perforation, warranting careful evaluation of the benefit-risk balance in these cases. While prophylactic pancreatic stenting may reduce the incidence of post-procedural pancreatitis, optimizing strategies to minimize overall adverse events remains a key focus for future research.

Clinical Case Summary

The endoscopic removal of polyps located at the appendiceal orifice is a challenge, particularly when extending inside the appendiceal lumen, due to its anatomic difficulty and risk of complications.
The endoscopic full-thickness resection (FTR) technique has become an non-surgical option for these lesions but with a non negligible risk of appendicitis.
With the present case we explore an alternative technique.
A 75-year-old man with iron deficiency anemia underwent upper digestive endoscopy and colonoscopy.
The upper digestive endoscopy was normal.
In the colonoscopy angiectasias were found in the cecum and multiple polyps in the left colon (the largest measuring 30 mm). The inspection of the appendix revealed an intra-appendiceal orifice lesion (Image A).
Only after inversion of the appendix it was possible to accurately assess the lesion: an approximately 15 mm sessile polyp (Images B, C).
We applied argon plasma for ectasias ablation and removed the left colon polyps by endoscopic mucosal resection.
Intra-appendiceal orifice polyp resection was performed underwater with a diathermic loop (Image D), with no immediate or late complications.
Histology revealed a sessile serrated adenoma with low-grade dysplasia.
The described technique, being a simpler, faster and cheaper option than the endoscopic-FTR is a valid and a cost effective one.

Introduction

The Tokyo Guidelines recommend a CRP cutoff >10 mg/L for diagnosing acute cholangitis. However, this threshold was defined in lithiasic populations and may not be applicable to malignant biliary obstruction, where CRP elevation often reflects tumor-driven inflammation rather than true infection. Applying this universal threshold in oncologic settings risks antibiotic overuse and promotes resistance.

Aims & Methods

This study aimed to reassess the diagnostic value of the current CRP cutoff in tumor-related cholangitis and to identify a more appropriate threshold to enhance specificity and guide targeted antibiotic use.
We conducted a retrospective monocentric study of consecutive patients at a tertiary center between May 2016 and October 2024. Among 571 patients undergoing ERCP, 268 patients with confirmed malignant biliary obstruction and available bile sampling were included. Bacteriological status was defined as positive when either direct bile examination or culture isolated microorganisms. CRP levels, leukocyte counts (hyperleukocytosis >10,000/mm³), and tumor etiology were recorded. ROC curve analysis was performed to determine the optimal CRP cutoff. Comparative analyses employed Mann-Whitney U, chi-square, and multivariate logistic regression.

Results

The mean age was 65.9 ± 12.4 years, with an equal sex distribution (50% male). Tumor etiologies included pancreatic cancer (56%), cholangiocarcinoma (22%) — 40 hilar and 18 distal cases, gallbladder cancer (13%), ampulloma (7%), and extrinsic or secondary compression (3%). The median CRP was significantly higher in culture-positive patients (47 mg/L [IQR 21–98]) compared to culture-sterile patients (22 mg/L [IQR 11–36]; p<0.001). ROC analysis identified an optimal CRP cutoff of 21 mg/L (AUC = 0.64), achieving a sensitivity of 67% and specificity of 54%. Hyperleukocytosis was present in 66% of culture-positive cases versus 31% of sterile cases (p<0.001). In multivariate analysis, CRP ≥21 mg/L (OR 2.1; 95% CI [1.3–3.4]; p=0.002) and hyperleukocytosis (OR 3.4; 95% CI [1.9–5.9]; p<0.001) were independently associated with bile bacteriological positivity.

Conclusion

In malignant biliary obstruction, the universal CRP threshold of 10 mg/L lacks specificity and risks antibiotic overuse. A higher threshold around 21–25 mg/L, combined with leukocyte count assessment, improves diagnostic precision. Our findings advocate for a context-specific adaptation of the Tokyo Guidelines to better differentiate tumor-related inflammation from true infection, ultimately enhancing patient safety and antimicrobial stewardship in oncologic care.

Introduction

Despite the progress in advanced therapies (AT) for ulcerative colitis (UC), selecting a second-line treatment after failure remains challenging. Recent guidelines recommend Ustekinumab (UST), Tofacitinib (TOFA), or Upadacitinib (UPA) as high-efficacy options after prior AT failure. However, no real-world studies have compared all three therapies.

Aims & Methods

Retrospective multicenter study (8 centers) of UC patients who failed ≥1 advanced therapy. Patients were stratified into UST, TOFA, or UPA groups and assessed at 16 and 52 weeks. The primary outcome was steroid-free clinical remission (SFCR) based on the Patient Reported Outcomes-2. Secondary outcomes included biochemical remission (fecal calprotectin ≤ 250 µg/g) and endoscopic remission (Mayo Endoscopic Subscore=0). Time to remission was assessed using Cox regression analysis. A subanalysis was performed including only second-line use after anti-TNF failure. Multivariate analysis was performed, adjusted for duration of disease, extent and number of prior therapies.

Results

We evaluated 259 cases [54.4% (n=141) female; diagnostic age 32.3 ± 15.1 years] who initiated UST (n=105; 40.5%), UPA (n=87; 33.6%) or TOFA (n=67; 25.9%). The groups were similar in disease duration (UST: 11.6 ± 8.0; UPA: 9.8 ± 6.4; TOFA: 10.4 ± 5.4 years) and 49.8% (n=129) had failed ≥2 previous AT
At week 16, UPA showed higher SFCR compared to UST (OR 2.1; p=0.014) and TOFA (OR 2.1; p=0.040), with no difference at week 52. Biochemical remission was higher with UPA at week 16 vs UST (OR 2.3; p=0.015) and TOFA (OR 2.1; p=0.039) and at week 52 vs UST (OR 4.7; p=0.010) and TOFA (OR 4.6; p=0.013). At week 16, endoscopic remission was higher with UST (OR 3.5; p=0.036) and UPA (OR 3.1; p=0.041) compared to TOFA; and at week 52, UPA was associated with higher endoscopic remission vs UST (OR 3.6; p=0.036).
In Cox regression, UPA achieved earlier biochemical remission than UST (HR 1.9; p<0.001) and TOFA (HR 1.8; p=0.011). JAK inhibitors led to earlier endoscopic remission than UST (vs UPA: HR 3.2; p<0.001; vs TOFA: HR 1.4; p=0.002).
In the subanalysis, UPA as second-line therapy demonstrated higher SFCR than TOFA (OR 3.6; p=0.035) and higher endoscopic remission at week 52 than TOFA (OR 12.0; p=0.017), and trend-wise compared to UST (OR 4.5; p=0.090).

Conclusion

Even though all three medication demonstrated high efficacy in bio-exposed UC patients, UPA achieved better results in this real world study.

References

Singh, Siddharth, et al. "AGA living clinical practice guideline on pharmacological management of moderate-to-severe ulcerative colitis." Gastroenterology 167.7 (2024): 1307-1343.

Introduction

The Maastricht V/ Florence Consensus has updated guidelines for the management of Helicobacter Pylori (HP) infection with special emphasis in high clarithromycin resistance settings as it is the case in our country. In line with the recommendations of the European Guidelines on surgery of severe obesity [1] and the recommendations of the American Society of Gastrointestinal Endoscopy on endoscopy of the bariatric patient [2) a policy of systematic HP screening and overtime updated eradication was implemented in obese patients undergoing Roux-en Y gastric bypass (RYGB) surgery.

Aims & Methods

Five year period (2020-2024) single center study. The aim was, in obese patients undergoing RYGB surgery, to assess the cumulative HP eradication rate by adopting, at first line, a 10 days bismuth quadruple therapy (BQT) - proton pump inhibitor (PPI) bid and three-in-one single capsule containing bismuth, metronidazole, and tetracycline qid - and, at second line, a 14 days levofloxacin based therapy ( LBT) – PPI bid, amoxicillin 1000 mg bid and levofloxacin 500mg bid. HP infection status was assessed, at baseline, by histology or urea breath test and post treatment, by urea breath test 4-6 weeks after the end of the therapy.

Results

One thousand four hundred and forty-nine consecutive HP‑positive patients completed BQT treatment: 1160 (80.1%) female, age 43.5 (±10.5) years, median age of 44 years), age range of 18-69 years. HP was eradicated in 1220 patients – 84.2% (95%CI: 82.2%-86.0%). In the remaining 229 patients, 87 patients withdrew and HP was eradicated in 118 patients out of 145 with LBT. The intention to treat (ITT) and per protocol (PP) cumulative eradication rates were, respectively, 92.3% (95%CI: 90.9%-93.6%). and 98.0% (95%CI: 97.1%-98.6%). Eradication rates were not significantly different by gender and age.

Conclusion

By adopting the Maastricht V/ Florence Consensus BQT first line therapy and second line LBT therapy, high ITT and PP cumulative HP eradication rates are achieved leaving only a residual number of obese patients undergoing RYGB in need of the culture and susceptibility testing prior to third line treatment.

References

1. Fried M, Hainer V, Basdevant A, et al. European Guidelines on surgery of severe obesity. . International Journal Of Obesity 2007;31:569-577.
2. ASGE Guidelines. Role of endoscopy in the bariatric patient. Gastrointest Endosc 2008; 68:1-10.

Disclosure

NO CONFLICT OF INTEREST