Introduction

The finding of low-grade dysplasia (LGD) in inflammatory bowel disease (IBD) guides clinical decision-making and carries major implications for affected individuals, often leading to intensive surveillance, repeated pathological assessments, and, in some cases, surgery. Progression rates from LGD to advanced dysplasia, including high-grade dysplasia (HGD) or colorectal cancer (CRC) vary considerably across studies, and defining individual risk remains challenging. One major challenge is the pathological assessment, which is time-consuming and complicated by morphological heterogeneity, concomitant inflammation, and interobserver variability. A recently developed and validated artificial intelligence (AI)-based cell quantifier enables automated identification and quantification of cells on digital histology slides. This cell quantifier is validated and predicts relapse-free survival in CRC.¹ We investigated whether macrophage density differed in areas with LGD versus surrounding tissue, and whether the density of macrophages in the area of LGD was related to progression from LGD to advanced dysplasia.

Aims & Methods

We conducted a case-control study including individuals diagnosed with IBD and LGD between 1994 and 2018 in the Central Denmark Region. Cases were defined as individuals who progressed from LGD to either HGD or CRC, and controls were matched on age, sex, and follow-up time using risk set sampling. For each participant, the first available LGD sample was identified, and H&E-stained slides were prepared and digitised. Areas with LGD were annotated by an expert pathologist, and the slides were subsequently analysed using the cell quantifier. When multiple samples were available, each was analysed separately. T-tests were used to compare macrophage density in the area LGD-marked area between cases and controls, and for each sample between areas with LGD and the surrounding tissue. Kernel density plots and Cox regression analyses with clustering and robust standard error were applied to further investigate the potential relation to progression.

Results

We identified 64 cases and matched 122 controls between 1994-2018, representing 233 samples with LGD due to multifocality. For all samples, sufficient tissue was retrieved, and the AI-based cell quantifier was applied without requiring alterations to standard slide preparation or model structure. A marked difference in macrophage density was observed between LGD areas and surrounding tissue (mean: 597.8 macrophages/mm² vs. 241.6 macrophages/mm², p < 0.001). Kernel density plots demonstrated a lower macrophage density in progressors. Belonging to the lowest quartile of macrophage density within the LGD area as relative to the combined other quartiles was associated with an almost twofold risk of progression to advanced dysplasia (p = 0.013).

Conclusion

AI-based tools enable novel and scalable quantification of cellular distribution in digital histological sections. In this study, a markedly higher macrophage density was observed within LGD areas compared to the surrounding tissue. Importantly, being in the lowest quartile of macrophage density within LGD areas was significantly associated with an increased risk of progression from LGD to advanced dysplasia.

References

1. Trahearn N, Sakr C, Banerjee A, et al. Computational pathology applied to clinical colorectal cancer cohorts identifies immune and endothelial cell spatial patterns predictive of outcome. J Pathol. 2025;265(2):198-210. doi:10.1002/path.6378

Introduction

In addition to gluten and a genetic predisposition, other external factors dictate the onset of coeliac disease (CeD). These, including the microbiota, have not yet been well characterised, but could explain why the disease occurs later in life in a large proportion of patients. Microbiota-associated barrier defects may contribute to this process.

Aims & Methods

Our aim was to investigate the potential of microorganisms to alter small intestinal epithelial polarity as well as epithelial barrier function - in particular with regard to epithelial gluten peptide uptake.
The study was designed in two phases. In the screening phase, the cell lines Caco2-Bbe and Caco2-PIP2 were exposed to different microorganisms. Caco2-PIP2 was stably transfected with a GFP-labelled PIP2 binding unit, which allowed for analysis of cell polarity. Read-outs in the screening phase included transepithelial resistance (TER), tight junction (TJ) integrity and epithelial polarity (IF and confocal imaging) and paracellular permeability by sandwich assay. In experimental phase II, the microorganisms (including a invasio-defective ALS3-mutant) were selected for a detailed analysis using human duodenal organoid 2D monolayers (isolated from healthy individuals and CeD patients). Read-outs included: TER, TJ integrity, epithelial polarity, 33mer-gliadin translocation and differential transcriptome analysis of bulk-RNA isolated from microbiota-exposed duodenal organoids.

Results

​Pseudomonas aeruginosa and Candida albicans were selected in phase I. They caused a decrease in TER by 90% and 95% of the original TER, respectively. Escherichia coli K12 and Saccharomyces cerevisiae were used as controls for P. aeruginosa and C. albicans, respectively. In phase II, both candidates revealed a reduced TER, an abolition of epithelial polarity and disrupted TJs as well as an increased epithelial 33mer uptake in CeD and control 2D organoids. Candida invaded – in an ALS3-dependent manner – the 2D organoid duodenal epithelia and thereby interacted with epithelial dynamin. On the other hand, differential gene expression of P. aeruginosa-exposed epithelia revealed altered apoptosis, barrier function and ion transport.

Conclusion

Our results suggest that distinct microorganisms can cause an epithelial barrier defect and increase 33mer transport in epithelial monolayers, thereby contributing to CeD immune pathology.

Introduction

Gastric cancer is a major cause of cancer-related mortality, and early detection improves outcomes. However, organized gastric cancer screening programs are largely absent in Europe, and vulnerable groups often have low awareness of preventive services. Roma communities face pronounced health disparities and barriers to healthcare, including social exclusion and low literacy, which may limit their use of preventive services [1].

Aims & Methods

We aimed to explore the knowledge, attitudes, and preferences regarding gastric cancer screening among Roma adults with low health literacy in Cluj-Napoca, Romania, to inform culturally tailored outreach strategies, as part of the TOGAS project. Approximately 40 Roma adults (18–72 years) were recruited via community centers for three focus groups (two urban, one rural) in Cluj-Napoca. All participants first attended a brief educational session on digestive health and gastric cancer to ensure baseline understanding. Guided by trained moderators, groups discussed their awareness of gastric cancer and perceptions of screening methods (endoscopy, blood tests, stool tests). All discussions were audio-recorded, transcribed, and thematically analyzed.

Results

Baseline awareness of gastric cancer screening was minimal. Most participants had never heard of any screening test or program for gastric cancer, indicating a major knowledge gap. Nevertheless, after receiving information, many expressed interest in screening for early detection. A prominent theme was communication preferences: nearly all participants preferred to receive health information via mobile phone or social media (e.g., messaging) and also through traditional channels like primary care providers. Overall, participants were open to screening if it was offered conveniently and respectfully.

Conclusion

Outreach is needed to improve engagement in cancer prevention among underserved populations. The lack of awareness in this Roma community echoes reports of poor knowledge of cancer prevention in other Roma groups and signals the need for targeted health promotion to reduce inequalities. As European health authorities consider implementing gastric cancer screening, input from vulnerable communities will be vital for equitable uptake.

References

1. Leja M. Where are we with gastric cancer screening in Europe in 2024? Gut. 2024 Nov 11;73(12):2074-2082.

Introduction

Increased intestinal permeability, mediated by zonulin, has been implicated in the pathogenesis of insulin resistance, dyslipidemia, and non-alcoholic fatty liver disease (NAFLD). Small intestinal bacterial overgrowth (SIBO) may further contribute to metabolic dysfunction through endotoxin-induced inflammation.

Aims & Methods

The aim was to determine zonulin concentrations in patients with dyslipidemia and NAFLD and analyze their relationships with metabolic parameters and the prevalence of small intestinal bacterial overgrowth (SIBO). A total of 342 patients with dyslipidemia were enrolled; NAFLD was confirmed in 152 of them based on ultrasound and steatometry. Fecal zonulin levels were measured using ELISA; SIBO was assessed by hydrogen breath test. Lipid profiles, high-sensitivity C-reactive protein (hsCRP), and HDL-C levels were also analyzed.

Results

Zonulin levels in patients with NAFLD (115±2.76 ng/g) exceeded the normal range (≤107 ng/g), compared to 87±0.28 ng/g in the dyslipidemia group without NAFLD (p<0.05). SIBO was present in 45% of dyslipidemic patients and 53.2% of those with NAFLD. A positive correlation was found between zonulin and hsCRP (r=0.65) and triglycerides (r=0.58), and a negative correlation between SIBO and HDL-C (r=–0.78) in the dyslipidemia group.

Conclusion

Elevated zonulin and increased intestinal permeability are associated with higher cardiometabolic risk in patients with NAFLD and dyslipidemia. Both zonulin and SIBO may serve as potential therapeutic targets for preventing progression of NAFLD and related metabolic disturbances.

Introduction

Gilbert's Syndrome (GS) is a benign polymorphism of the UGT1A1 gene, leading to decreased enzyme activity in the liver and mildly increased levels of unconjugated bilirubin in blood (= hyperbilirubinemia), that is affecting 5-12% of the worldwide population. A mild hyperbilirubinemia (HBIL) is associated with reduced chronic inflammation, a lower risk for metabolic and cardiovascular disorders, and lower levels of reactive oxygen species (ROS). Despite these associations, HBIL effects on the intestine, as the primary site of bilirubin excretion, and its interactions with the gut microbiota remain unclear. We propose that chronic HBIL redirects bilirubin excretion through the intestinal epithelium that affects microbe-host interactions in the colon.

Aims & Methods

Germ-free (GF) and specific-pathogen-free (SPF) C57BL/6N wildtype (WT) mice with induced HBIL and transgenic mice with the human UGT1A1*28 polymorphism (TG) were investigated, the latter one mimicking chronic HBIL. WT mice with induced HBIL received intraperitoneal bilirubin injections for 12-14 days. Bilirubin levels, in the intestine, gut content and serum were analyzed using the fluorescent protein UnaG, which specifically binds to unconjugated bilirubin, and microbiota composition was analyzed by 16S rRNA gene sequencing. To characterize HBIL-associated antioxidative function, colonic adenoma cell lines (Ptk-6, HCT116, HT-29-MTX-E12) and small intestinal organoids were incubated with different levels of bilirubin and the generation of ROS and oxidative stress markers measured.

Results

In general, mice of the induced HBIL groups exhibited higher bilirubin levels in the colonic mucosa, indicating "intestinal HBIL" with increased concentrations of mucosal bilirubin being detected in SPF HBIL > GF HBIL mice (SPF HBIL = 12.34 nM/mg, GF HBIL = 9.9 nM/mg; SPF control = 0.5951 nM/mg; GF control = 8.21 nM/mg), as well as a lower hepatic Ugt1a1 expression. Intracellular uptake of bilirubin was confirmed when different human and murine colonic epithelial cell lines were treated with bilirubin in vitro. Intestinal HBIL led to altered gut microbiota compositions, characterized by decreased abundances of operational taxonomic units (OTUs) associated with Gram-negative taxa (e.g., Prevotellaceae) and increased levels of OTUs associated with Gram-positive taxa (e.g., Lachnospiraceae) under intestinal HBIL conditions. Gut microbiota changes were more pronounced in TG (=chronic HBIL) compared to induced HBIL mice. In vitro experiments showed decreased detection of ROS and markers of cellular oxidative stress in a HCT116 reporter cell line dependent on bilirubin presence (Nfk-⁠β, Nrf2 and Hif1α). Small intestinal organoids from TG mice showed an altered proliferation pattern in comparison to WT organoids.

Conclusion

The results suggest an altered bilirubin excretion through the intestinal epithelium under mild HBIL that alters gut microbiota composition. These effects were more pronounced under chronic HBIL conditions, suggesting a sustained effect of GS-like HBIL on the gut microbiota.

Introduction

Endoscopic submucosal dissection (ESD) for early upper gastrointestinal (GI) tumors creates large mucosal defects with risks of bleeding, perforation, and strictures, particularly in the esophagus where post-ESD stricture rates reach clinically significant levels. Current closure methods are inadequate for managing esophageal defects due to anatomical complexity. We present an endoscopy-integrated platform for real-time in situ nanofiber deposition during upper GI ESD, leveraging blow spinning technology to address these limitations.

Aims & Methods

This study aimed to
(1) engineer a coaxial nozzle system compatible with standard upper GI endoscopes (working channel ≤3.7 mm),
(2) optimize nanofiber deposition parameters for esophageal wound repair, and
(3) validate therapeutic efficacy in preclinical models.
A simplified in vitro setup was used to optimize polymer composition (polycaprolactone/gelatin blends), gas pressure (0.2-0.5 MPa), and blowing distance (10-20 cm). A murine skin wound model was employed to validate nanofiber adhesion and repair properties. For endoscopic integration, a dual-layer coaxial nozzle was designed using computational fluid dynamics (CFD), featuring an inner polymer delivery channel (0.5 mm inner diameter) and an outer airflow channel (1.2 mm inner diameter) to generate nanofibers via controlled airflow. The nozzle was fabricated using stereolithography 3D printing with biocompatible resins and integrated into a compact endoscopic system. Functional testing was performed in a transparent esophageal phantom under simulated physiological flushing, followed by in vivo validation in a porcine esophageal ESD model comparing nanofiber-treated wounds to controls.

Results

The 3D-printed coaxial nozzle (3.0-mm outer diameter) demonstrated full compatibility with standard upper GI endoscopes. In simulated esophageal conditions, the platform achieved uniform nanofiber deposition (fiber diameter: 15.2±3.6 μm) with robust adhesion unaffected by luminal flushing. In the porcine esophageal ESD model, immediate nanofiber application provided complete wound coverage, reduced perioperative bleeding, and prevented stricture formation. Histological analysis at 4 weeks revealed markedly reduced fibrosis and enhanced mucosal regeneration in treated groups compared to controls. The system operated seamlessly within the standard ESD workflow without procedural interference.

Conclusion

This study develops the first endoscopy-compatible platform for real-time in situ nanofiber deposition, demonstrating preclinical efficacy in addressing post-ESD complications in the upper gastrointestinal tract. By synergizing mechanical barrier formation with bioactive healing modulation, the technology reduces stricture risks and promotes mucosal repair in porcine esophageal ESD models. While current findings underscore its translational promise, further optimization of biomaterial formulations and rigorous human trials are essential steps toward clinical adoption in therapeutic upper GI endoscopy.

Introduction

Although patients with acute-on-chronic liver failure (ACLF) often demonstrate preserved thrombin generation (TG), they concurrently display hypocoagulable profiles on rotational thromboelastometry (ROTEM) [1]. The extent to which these findings explain the increased bleeding risk in acutely ill cirrhotic patients remains unclear [1–5]. Moreover, most studies do not distinguish between portal hypertensive (PH) and non-PH bleeding, complicating accurate estimation of NPH bleeding prevalence.

Aims & Methods

This is a case-control study, comparing haemostatic profiles of acute decompensation (AD) and ACLF (=cases) to stable cirrhosis (SC) (=controls). Coagulation profiles were evaluated including INR, aPTT, PT, fibrinogen, coagulation factors and inhibitors and advanced global haemostatic tests (ROTEM, TG assay (TGA) ± thrombomodulin (TM)). Secondary objectives focused on identifying associations between coagulation parameters and NPH bleeding and thrombotic events.

Results

A total of 215 patients were included (SC: 122; AD: 53; ACLF: 40). The median Child-Pugh (CP) and MELD-Na scores increased progressively from SC to AD to ACLF (P< 0.001). NPH bleeding occurred in 8,4% (n=18), with higher rates in ACLF (30,8%, P<0,001) and AD (18.9%, P=0.011) than in SC (5.7%). Thrombotic events were observed in 7.0% (n=15).
TGA without TM revealed that ACLF patients had significantly shorter lag time compared to SC, shorter time to peak, reduced peak height and endogenous thrombin potential (ETP) compared to SC/AD; though TM normalized these effects. ETP inhibition by TM was reduced significantly across the three groups. ROTEM parameters showed marked hypocoagulable features in ACLF vs SC/AD, while AD and SC were comparable. Hypocoagulability (≥5 abnormal ROTEM parameters out of 6 parameters) was present in 1.8% of SC, 8.3% of AD, and 22.2% of ACLF patients (P<0.001 for SC vs ACLF); hypercoagulability was rare (2.8% in ACLF). INR and aPTT were significantly prolonged and FVIII elevated, while fibrinogen, PT, and pro- and anticoagulants were reduced in AD/ACLF compared to SC. ROTEM and TGA parameters correlated significantly with MELD-Na and CP scores (P<0,001).
Patients with NPH bleeding had higher CP and MELD-Na scores (P<0,001 and P=0,006), and a greater prevalence of AD (33,3%) and ACLF (38,9%) compared to non-bleeders (22,8% AD; 16,1% ACLF). Hypocoagulability on ROTEM was more frequent among bleeders (31.3% vs 4.5% in non-bleeders, P=0.002). Bleeders also showed greater impairment in INR, aPTT, PT, and most coagulation factors (except FVIII and PS). Multivariate analysis identified ROTEM-defined hypocoagulability as an independent risk factor for NPH bleeding (OR 12.93, 95% CI: 1.13–150.28, P=0.041). No significant differences in coagulation parameters were observed between patients with and without thrombotic complications.

Conclusion

TG demonstrated accelerated initiation and reduced thrombin potential in ACLF vs SC/AD, though TM normalized these effects. ROTEM demonstrated pronounced hypocoagulability in AD/ACLF vs SC. These coagulation abnormalities are paralleling their advanced liver dysfunction.
NPH bleeding events clustered in AD/ACLF cohorts and were associated with ROTEM-defined hypocoagulability. The convergence of ROTEM hypocoagulability as an independent risk factor for NPH bleeding and its prominence in acutely ill cirrhotic patients underscores the heightened NPH bleeding prevalence and ROTEM detected coagulation dysfunction in this patient population.

References

1. Campello E, Zanetto A, Bulato C, Maggiolo S, Spiezia L, Russo FP, et al. Coagulopathy is not predictive of bleeding in patients with acute decompensation of cirrhosis and acute‐on‐chronic liver failure. Liver International. 2021 Oct 16;41(10):2455–66.
2. Drolz A, Horvatits T, Roedl K, Rutter K, Staufer K, Kneidinger N, et al. Coagulation parameters and major bleeding in critically ill patients with cirrhosis. Hepatology. 2016 Aug 9;64(2):556–68.
3. Blasi A, Calvo A, Prado V, Reverter E, Reverter JC, Hernández‐Tejero M, et al. Coagulation Failure in Patients With Acute‐on‐Chronic Liver Failure and Decompensated Cirrhosis: Beyond the International Normalized Ratio. Hepatology. 2018 Dec 9;68(6):2325–37.
4. Bihari C, Patil A, Shasthry SM, Baweja S, Kumar G, Sarin SK. Viscoelastic test-based bleeding risk score reliably predicts coagulopathic bleeding in decompensated cirrhosis and ACLF patients. Hepatol Int. 2020 Jul 17;14(4):597–608.
5. Ow TW, Fatourou E, Rabinowich L, van den Boom B, Nair S, Patel VC, et al. Prevalence of Bleeding and Thrombosis in Critically Ill Patients with Chronic Liver Disease. Thromb Haemost. 2022 Jun 12;122(06):1006–16.

Disclosure

The reagents for the ROTEM analyses were sponsored by Werfen. This study received a Gilead fellowship, and K.F. received a BSTH-CSL Behring encouragement award.