Clinical Case Summary

Male, 72 years old, past medical history of diabetes mellitus and diabetic gastroparesis with only partial improvement after medical treatment with prokinetics, antiemetics and oral antidiabetic drugs.
Due to gastric adenocarcinoma, he underwent curative submucosal dissection(ESD) 2 years before and developed pyloric stenosis 1 month after ESD, refractory to endoscopic dilation and not amenable to placement of a biodegradable stent due to stomach morphology.
The patient was admitted to the to the Emergency Department after 2 weeks of postprandial vomiting, weight loss(12%/1 month) and 2 days of disorientation. On examination, he was partially oriented, hemodynamically stable, with mucocutaneous dehydration.
He was hospitalized, started on prokinetics and a nasogastric tube was placed for drainage. Analysis results on admission were normal except for a cystitis and empirical antibiotic was initiated.
During hospitalization, he suffered acute depression of consciousness with stupor and bilateral ophthalmoplegia, followed by delirium.
CT angiography excluded acute vascular events and cerebrospinal fluid(CSF) cytochemical analysis was normal.
Due to clinical suspicion of Wernicke's encephalopathy, he was started on intravenous thiamine at therapeutic dose, anticonvulsant, antibiotic at meningeal dose and antiviral, while waiting for microbiological results.
MRI revealed hypersignal in T2 and FLAIR with restriction in the diffusion study in the midbrain and the thalamus - findings suggestive of Wernicke's Encephalopathy. The remaining study, including EEG and complete CSF analysis excluded other etiologies.
There was a progressive improvement of aphasia, apraxia, ataxia and nystagmus. After motor rehabilitation and vitamin supplementation, 6 months later, he maintains a short-term memory deficit (Korsakoff Syndrome).
Wernicke's Encephalopathy due to gastroparesis is a rare occurrence in the literature with potentially irreversible sequelae, as illustrated.

References

Introduction

Patients with ulcerative colitis (UC) report that UC negatively affects their quality of life (QoL), including sexual functioning, satisfaction, and drive.^1,2 These effects are rarely discussed with or by gastroenterologists in clinical practice. The CONFIDE study aims to elucidate the impact of symptoms on the lives of patients with moderate to severe UC in the United States (US), Europe (EU5; France, Germany, Italy, Spain, and UK), and Japan. Data presented here are from the US and EU5.

Aims & Methods

Online, quantitative, cross-sectional surveys were conducted (July–September 2021). Criteria based on previous treatment, steroid use, and/or hospitalization were used to define moderate-to-severe UC. Data collected included patient perspectives on the impact of UC on sexual activity. Sexual activity was not limited to intercourse and included activities such as masturbation.

Results

Surveys were completed by 200 US patients (male [M]=62%, mean age 40 years) and 556 EU5 patients (M=57%, mean age 39 years). Of these, 77% US and 54% EU5 patients were receiving advanced therapy (biologic/novel oral) and 52% and 73% were receiving steroids at the time of survey completion, respectively. Overall, 63% US patients (M=55%, female [F]=77%) and 53% EU5 patients (M=47%, F=60%) reported avoiding or decreasing sexual activity due to UC in the 3 months prior to the survey. Among these patients (US: N=126; EU5: N=292), most frequently reported reasons for avoidance of sexual activity were bowel urgency (BU; 41%), decreased sexual desire (37%), and fear of BU-related accidents (34%) in the US and fear of faecal seepage (37%), fear of BU-related accidents (36%), and BU itself (31%) in EU5. Although reasons for avoiding sexual activity were broadly similar between sexes, higher percentage of male patients from both US and EU5 (US: M=33%, F=24%; EU5: M=42%, F=33%) reported fear of faecal seepage as a factor affecting sexual activity. Conversely, higher percentages of female patients reported perianal pain (M=13%, F=19%) and self-consciousness (M=13%, F=24%) as reasons for avoiding sexual activity in the US and decreased sexual desire (M=16%, F=26%), BU (M=26%, F=36%) and fatigue (M=14%, F=22%) in EU5.

Conclusion

In both US and EU5 populations, >50% patients with moderate-to-severe UC reported avoiding or decreasing sexual activity due to UC, with bowel urgency and bowel urgency-related accidents being among the top three reasons. In addition to other QoL parameters, impact of UC on patients’ sexual health needs to be assessed in routine clinical practice.

References

¹Bulut AE, et al. Turk J Gastroenterol. 2019;30:33-39.
²Jedel S, et al. Inflamm Bowel Dis. 2015;21:923-38.

Disclosure

Simon Travis, Grants: Ferring Pharmaceuticals, AbbVie, Schering-Plough, MSD, Procter & Gamble, Warner Chilcott, International Organization for the Study of IBD, ECCO, UCB, Vifor Pharma, Normal Collision Foundation, Buhlmann, Takeda, Janssen, Pfizer, and Eli Lilly and Company.
Marla C. Dubinsky, Consultancy fees: AbbVie, Arena Pharmaceuticals, Boehringer Ingelheim International GmbH, Bristol Myers Squibb, Celgene Corporation, Eli Lilly and Company, F. Hoffman-La Roche Ltd, Genentech Inc., Gilead Sciences, Janssen, LLC, Pfizer, Prometheus Biosciences, Takeda Pharmaceuticals USA, Inc., and UCB; Stockholder: Trellus Health Inc.; Research support: AbbVie, Janssen, LLC, Pfizer, and Prometheus Biosciences.
Toshifumi Hibi, Consultancy fees/grant/research support/speaker: AbbVie GK, ActivAid, Alfresa Pharma Corporation, Apo Plus Station, Aspen Japan K.K, Bristol-Myers Squibb, Celltrion, EA Pharma, Eli Lilly and Company, Ferring Pharmaceuticals, Gilead Sciences, Janssen, JIMRO, JMDC Inc., Kyorin, Mitsubishi-Tanabe Pharma Corporation, Mochida Pharmaceutical, Nichi-Iko Pharmaceutical, Nippon Kayaku Co. Pfizer, Takeda Pharmaceutical, Zeria Pharmaceutical, and MIYARISAN Pharmaceutical.
David T. Rubin, Grants/contracts: Takeda; Consultancy fees: AbbVie, Altrubio Inc., Allergan, Inc., American College of Gastroenterology, Arena Pharmaceuticals, Athos Therapeutics, Bellatrix Pharmaceuticals, Boehringer Ingelheim International GmbH, Bristol Myers Squibb, Celgene Corp/Syneos, Cornerstones Health, Inc. (non-profit), GalenPharma/Atlantica, Genentech/Roche, Gilead Sciences, GODURN, LLC, InDex Pharmaceuticals, Ironwood Pharmaceuticals, Iterative Scopes, Janssen, Eli Lilly and Company, Materia Prima, Pfizer, Prometheus Biosciences, Reistone Biopharma, Takeda, and Techlab Inc; Stockholder: Altrubio and Datos Health.
Remo Panaccione, Consultancy/speaker fees and/or advisory board member: AbbVie, Amgen, Arena Pharmaceuticals, Bristol-Myers Squibb, Celgene, Eli Lilly and Company, Ferring, Fresenius Kabi, Gilead Sciences, Janssen, Merck, Organon, Pfizer, Roche, Sandoz, Shire, and Takeda; Consultancy fees and/or advisory board member: Alimentiv, AstraZeneca, Biogen, Boehringer Ingelheim, Genentech, Glaxo-Smith Kline, JAMP Bio, Mylan, Novartis, Oppilan Pharma, Pandion Pharma, Progenity, Protagonist Therapeutics, Sublimity Therapeutics; Consultancy fees: Abbott, Celltrion, Cosmos Pharmaceuticals, Eisai, Elan, Galapagos, JAMP Bio, Pendopharm, Satisfai Health, Theravance Biopharma, Trellus, Viatris, and UCB.
Stefan Schreiber, Consultancy and lecture fees: AbbVie, Amgen, Arena Pharmaceuticals, Bristol Myers Squibb, Celltrion, Falk, Ferring Pharmaceuticals, Galapagos/Gilead, Genentech/Roche, Eli Lilly and Company, Janssen, MSD, Pfizer, and Takeda.
Christian Atkinson, Employee: Adelphi Real World; Consultancy: Eli Lilly and Company in connection with this study.
Alison P. Bleakman, Cem Kayhan, Theresa H. Gibble, Christophe Sapin, and Eoin J. Flynn are employees and stockholders of Eli Lilly and Company.

Introduction

Gastroenterology (GE) is a medical discipline that studies all diseases of the digestive system. It comprises several areas of study and offers a large variety of sub-specializations: proctology, interventional endoscopy or even digestive oncology. The decisive elements in the choice of this specialty vary among interns. The aim of our study is to determine the various factors influencing the choice of gastroenterology as a specialty among medical interns.

Aims & Methods

This is a cross-sectional, multicentric, survey-type study, conducted from September 1 to 30, 2023, involving 7 national medical faculties. All medical interns, regardless of sex or age, participated in our study.
An electronic survey with 29 items was created using Google Forms®. It was divided into two parts: the first part contained 13 questions on socio-demographic characteristics and exposure to GE during the academic curriculum, while the second part concerned the factors motivating the choice or not of GE as a specialty.
A statistical analysis using the Fisher’s exact test was performed. P values of <0.05 were considered statistically significant. Data were analyzed using Jamovi (Version 2.3).

Results

A total of 329 responses were collected: the majority were women 208 (63.2) with a F/M sex ratio of 1.7 and a median age of 27 [25; 28] years. The majority had already completed a GE rotation during their training course n=205 (62.3), of which 90 (44.1) had found it "satisfactory". More than half of the participants n= 178 (54.1) had already considered GE as a future specialty, and this choice was mostly made during GE lectures given in medical school n= 66 (36.9). Among those who had never considered GE, the main reasons were lack of interest in the specialty, the fact that it is a medical specialty, lack of information about GE, potential remuneration, and dissatisfaction with GE rotation during the training course (59.2%, 28.9%, 13.9%, 10.4% and 10% respectively).
Among those who finally opted for GE, the majority were women (70.2% vs. 29.8%, p=0.004). Satisfaction with the GE rotation during the training course had an impact on the final choice: "satisfactory" vs. "mediocre" (43.8% vs. 6.3% p=0.009).
Multivariate analysis showed that early interest in fields such as endoscopy (OR= 4.46, CI95%: 1.44-13.78, p=0.009) or proctology (OR= 4.26, CI95%: 1.01-18.01, p=0.05) increased the chance of choosing GE.

Conclusion

This study showed that there is a gender disparity in the choice of GE as a specialty. The fact that it is a medical discipline may lead men to choose another path. Our study also highlighted the importance of GE training courses during the medical curriculum to motivate interns to join our specialty, as well as the need to spotlight certain areas such as endoscopy or proctology.

Introduction

Colonoscopy is the ‘gold standard’ investigation for assessment of the large bowel allowing diagnosis, biopsies, and therapy to be undertaken. Colonoscopy detects and prevents colorectal cancer through detection and removal of polyps, and is important in the diagnosis and treatment of non-neoplastic conditions. Poor quality colonoscopy is associated with increased rates of interval cancers. High quality colonoscopy cannot occur without good quality bowel preparation. Evidence in the UK show that 22% of failed colonoscopies were due to poor bowel preparation. Apart from the bowel cleansing agent, dietary restriction prior to colonoscopy has been shown to enhance quality of bowel preparation at colonoscopy.

Aims & Methods

We aimed to assess the information received and followed by patients in terms of dietary modification prior to colonoscopy.
A single centre prospective analysis of 60 consecutive patients attending colonoscopy at Chase Farm Hospital in London was undertaken in May 2022. Patients were asked to complete a questionnaire with information gathered about: type of bowel prep undertaken, whether written information about how to take bowel prep was received, whether a telephone consultation explaining dietary restriction prior to procedure happened, whether they followed a low fibre diet and the amount of fluid drunk.

Results

57 patients returned the questionnaire.
Of the 57 patients, 39% patients received written information on dietary restriction. A further 35% of patients received telephone information, 26% of patients receiving both written and verbal information. 56.9% of patients followed the 3 day dietary restriction. The quality of bowel preparation was inadequate (fair and poor by Aronchick scale) in 60% of those who did not follow the low fibre diet compared to 24% when followed. Patients who had seen a clinician in clinic and patients undergoing surveillance procedure were more likely to follow dietary restriction compare to direct access patients.

Conclusion

In this prospective study of clinical practice, we conclude that advice regarding dietary fibre restriction prior to colonoscopy is variable. In clinical practice, there is low compliance of dietary restriction prior to colonoscopy. We find that those who followed a low fibre diet are 40 % more likely to have a favourable bowel preparation compared to those following a high fibre diet. Those that had inadequate bowel prep required a repeat colonoscopy adding to the burden of the already stretched service. We recommend improvements in the implementation of the low residue diet in addition to the guidance of cleansing agents prior to colonoscopy.

Introduction

Superficial esophageal squamous cell carcinoma (SESCC) was enabled detection by the innovation of Narrow Band Imaging (NBI). However, NBI has insufficient sensitivity for detecting SESCC when used by inexperienced endoscopists.¹⁾ To solve these problems, the construction and usefulness of endoscopic detection models for SESCC using artificial intelligence (AI) have been reported.²⁾ On the other hand, the assistant effect of the AI model for endoscopists has not been fully examined.

Aims & Methods

The aim of this study is to create an AI model to assist in detecting SESCC and to assess the effect of the AI assistance on the endoscopist's diagnostic performance using endoscopic video. We collected endoscopic videos of cases with lesions and without lesions from May 2020 to September 2021 for training data to create an AI model for detecting SESCC and from October 2021 to January 2022 for test data. All videos were taken 3 to 5 seconds at National Cancer Center Hospital East by using NBI. Eligibility criteria for cases with lesions were as follows: i) histopathologically diagnosed ESCC or high-grade intraepithelial neoplasia (HGIN); ii) the depth of lesion shallower than cMM/SM1. Residual lesions after endoscopic resection for ESCC were excluded. The eligibility criteria for cases without lesions were the absence of ESCC or HGIN by endoscopic diagnosis. Patients with a history of chemotherapy, radiotherapy, chemoradiotherapy, or surgery for ESCC were excluded. The performances of the AI model and 18 endoscopists (8 experts and 10 non-experts) for detecting SESCC were evaluated using the test data. Furthermore, to explore the assistance ability of the AI model, the endoscopists were required to diagnose again on the same test data after 4 weeks, referring to the results predicted by the AI model. The diagnostic performance of the endoscopists with and without the AI assistance was compared to assess the sensitivity, specificity, accuracy, and interobserver agreement. The recognition to the lesions by the AI model was defined to detect with Intersection over the Union > 0.3 for 5 consecutive frames for each video. The results of the endoscopists were presented as averages.

Results

We collected 280 cases (140 with lesions and 140 without lesions) videos as training data and 115 cases (52 with lesions and 63 without lesions) videos as test data. The clinicopathological characteristics of the lesions were as follow: median lesion size was 15mm (range:1-100mm), and the pathological depth of tumor were EP/LPM/MM/SM1/SM2=10/17/0/4/4/4. The sensitivity, specificity, and accuracy of the AI model were 76.0%, 79.4% and 77.2% respectively. With the AI assistance, the sensitivity and accuracy of the endoscopists were significantly improved (without vs with the AI assistance: 57.4% vs 66.5%, P<0.05, 68.6% vs 75.9%, p<0.05), while the specificity were slightly improved (87.0% vs 91.6%, P=0.059). For experts, the sensitivity and accuracy were significantly improved (59.1% vs 70.0%, P<0.05, 72.1% vs 79.3%, p<0.05). For non-experts, the accuracy was significantly improved (65.8% vs 73.3%, P<0.05), while the sensitivity and specificity were slightly improved (56.1% vs 63.7%, P=0.07, 81.9% vs 89.2%, p=0.07). The interobserver agreement for diagnosis among the endoscopists was improved with the AI assistance (κ=0.429 vs κ=0.547).

Conclusion

The assistance of the AI model improved the endoscopist's sensitivity of detection of SESCC without reducing the specificity, regardless of their experience. The AI model would be effective in improving the endoscopist's ability to detect SESCC in practice.

References

1) Ishihara R, Takeuchi Y, Chatani R et al. Prospective evaluation of narrow-band imaging endoscopy for screening of esophageal squamous mucosal high-grade neoplasia in experienced and less experienced endoscopists. Dis Esophagus 2010; 23: 480–6.
2) Waki K, Ishihara R, Kato Y et al. Usefulness of an artificial intelligence system for the detection of esophageal squamous cell carcinoma evaluated with videos simulating overlooking situation. Digestive Endoscopy 2021; 33: 1101–1109.

Introduction

Cancer is the second leading cause of death globally. Colon cancer is the fifth most prevalent type of cancer. Screening, particularly colonoscopy, reduces incidence by 40% and mortality by 50%. The process of bowel preparation before a colonoscopy is complex and requires the patient’s compliance. Enhanced education using a smartphone application has been shown to improve bowel preparation quality. However, heterogeneity was observed among the studies.

Aims & Methods

AIMS: To determine if providing instructions through an application enhances bowel preparation quality in Thai patients undergoing elective colonoscopy.

METHODS: From July 2022 to January 2024, a prospective, endoscopist-blinded, randomized, controlled trial was conducted. Consecutive patients aged > 18 years old who had convenient access to the Line application were randomly assigned in a 1:1 ratio to be educated via the smartphone application (APP group) or the standard education (control group). All patients received the same purgative regimen. The primary outcome was the Boston Bowel Preparation Scales (BBPS). Secondary outcomes included adenoma detection and cecal intubation rates, cecal intubation time, withdrawal time, and patient satisfaction.

Results

The trial aims to recruit 488 patients. A total of 272 patients (APP group, n = 131; control group, n =141) were preliminary analyzed. The mean age was 61.5 years old, and 29% were male. The mean BBPS was comparable between the APP and control groups (8.30 ± 0.99 vs 8.51 ± 1.19, P = 0.173). Both groups achieved adequate bowel preparation (BBPS>6) in 99.2% of cases. All secondary outcomes corresponded with the primary outcome. In the subgroup analysis among the elderly, levels of education, income, and waiting times for colonoscopies, BBPS was not impacted by the providing methods. No adverse events related to education were observed.

Conclusion

Both standard and enhanced education using the smartphone application resulted in excellent bowel preparation. Eligible patients included in this study might influence this outcome. However, using the smartphone application was well-received and could potentially replace standard education for bowel preparation.

References

1. Virani S, Bilheem S, Chansaard W, Chitapanarux I, Daoprasert K, Khuanchana S, et al. National and Subnational Population-Based Incidence of Cancer in Thailand: Assessing Cancers with the Highest Burdens. Cancers. 2017;9(8):108.

2. May FP, Shaukat A. State of the Science on Quality Indicators for Colonoscopy and How to Achieve Them. Official journal of the American College of Gastroenterology | ACG. 2020;115(8):1183-90.

3. Desai M, Nutalapati V, Bansal A, Buckles D, Bonino J, Olyaee M, et al. Use of smartphone applications to improve quality of bowel preparation for colonoscopy: a systematic review and meta-analysis. Endosc Int Open. 2019;7(2):E216-E24.