Introduction

Inflammatory bowel disease (IBD) is a growing cause for concern and often missed or not thought of among pediatric population in developing economies. It is reported that about 25% of IBDs present before the age of 20.
Growing plethora of investigations have not been able to replace the role of direct visualisation of intestinal mucosa in various colorectal issues. Macroscopic findings may or may not help in clinching the diagnosis of IBD, hence “Biopsy” remains the Elixir of diagnosis. In this article, we review and attempt to correlate colonoscopic(macroscopy) and histological (microscopy) findings of colonoscopies in pediatric population, done over a period of 1 year.

Aims & Methods

Aim and objectives: To compare macroscopic findings versus histopathology findings of colonoscopies in pediatric population in suspected IBD.
To study the correlation of macroscopic findings with histopathologic findings of colonoscopies in pediatric population and to assess the frequency and pattern of microscopic impressions of colonoscopies in our cohort.
Material and methods: A prospective observational study carried out in a tertiary referral centre in children who underwent colonoscopies, aged 1 month to 17 years over a period of 12 months.
All children whose parents consented were included in the study. Inclusion and Exclusion criteria were formulated. Informed consent was obtained from the parents. Clinical details, colonoscopy findings and histopathology reports were. A total of 135 cases were enrolled during our study period. Results were collated using Microsoft Excel ™.
© Ethical clearance was obtained from the institutional ethical committee.

Results

We found that the diagnosis of IBD was much more specific than expected with good sensitivity when data was matched between Macroscopy and Microscopy

Conclusion

• It is our standard practice to do colonoscopic biopsies from 7 areas (terminal ileum, cecum, ascending colon, transverse colon, descending colon, sigmoid colon, rectum) of the colon to exclude microscopic colitis which may be missed by the endoscopist or marked as ‘normal’.
• Microscopic findings are considered as ‘Gold standard’ in the diagnosis of IBD and we envisage that it will remain the gold standard in the many next decades to come
• Our data of sensitivity and sensitivity of the microscopic findings inclined the relevance of colonic mucosal biopsies in children with a normal-appearing mucosa and also the need to analyse every segment of the colon to diagnose IBD that may masquerade as “normal” in children which will add burden to the family, society and health care system and more importantly to the child’s quality of life.

References

1. Manfredi, Michael A et al. “Good agreement between endoscopic findings and biopsy reports supports limited tissue sampling during pediatric colonoscopy.” Journal of pediatric gastroenterology and nutrition vol. 58,6 (2014): 773-8.
2. Altamimi, Eyad & Odeh, Yousef & Al-Quraan, Tuka & Mohamed, Elmi & Rawabdeh, Naif. (2022). Diagnostic and therapeutic outcomes of pediatric colonoscopies in Jordanian children. Journal of Pediatric and Neonatal Individualized Medicine. 11.

Introduction

Inflammatory bowel disease (IBD) is a chronic condition of the gastrointestinal tract. Around 20% of patients develop at least one extraintestinal manifestation, the most frequent being articular, followed by cutaneous, ocular and hepatobiliary. Among those involving the skin, erythema nodosum (EN) and pyoderma gangrenosum (PG) are frequently observed.

Aims & Methods

Our aim was to describe the characteristics of PG and EN in both ulcerative colitis (UC) and Crohn’s disease (CD), and provide a detailed description of their treatment, prognosis and their impact on IBD management. This was a retrospective, multicenter study including all patients with a diagnosis of EN or PG between January 2013 and February 2023. Patients were identified from the ENEIDA registry, a prospectively-maintained database supported by GETECCU. Demographic and clinical characteristics (subtype, date of diagnosis, number of cutaneous lesions, distribution, and location), along with therapeutic requirements and prognosis were registered. Descriptive statistics were used, followed by non-parametric comparisons by chi-square tests.

Results

A total of 542 patients (401 with EN and 141 with PG) fulfilled the inclusion criteria among 52,555 IBD patients included in the ENEIDA registry at the time of data extraction.
EN was predominantly observed in women (77%), with a mean age of 47 years (SD 15) and CD (76%). It was mostly located in the lower limbs (97%), followed by upper limbs (9%); lesions were frequently multiple (75%) and bilateral (65%). EN modified the management of IBD in 18% of cases. Steroids were the most frequently used drugs (73% oral, 17% topical, 13% iv); 18% of patients were treated with biologicals, mostly anti-TNF agents. After 8 weeks of diagnosis, partial response was observed in 19% of patients, and remission in 77%. Recurrence rate of EN was 21%, with 60% of patients developing multiple episodes.
PG was mainly seen in women (60%), with a mean age 52 years (SD 14) and UC (52%). It was usually located in the lower limbs (75%), but it was also observed in arms, thorax or periostomal (12-13%). The most common type was classic (77%), followed by pustular (19%). Multiple lesions were observed in 56% of patients and unilateral distribution in 62%. PG modified the management of IBD in 29% of cases. Oral steroids were commonly used (54%), followed by biological agents (38%), oral antibiotics (27%), and cyclosporin (18%). PG modified the management of IBD in 29% of cases. After 8 weeks of diagnosis, 49% of patients showed partial response and 43% achieved complete remission. Recurrence rate of PG was 21%, with 55% of them developing multiple episodes.

Conclusion

Up to 1% of patients in the ENEIDA registry developed EN and/or PG. They are usually located in the lower limbs and with multiple lesions. Steroids are the mainstay of their treatment, being anti-TNF the main biological agents. These cutaneous manifestations modify the clinical management of IBD in 21% of cases. Clinical remission rates are higher in EN than in PG, although recurrence occurs in one fifth of patients.

Introduction

Malnutrition and sarcopenia are two very frequent complications in patients with liver cirrhosis (LC). These conditions are associated with increased morbidity and mortality, particularly in advanced stages and require early investigation. Despite their significant impact on the prognosis, they are often overlooked and underdiagnosed.

Aims & Methods

Aim: To provide a general overview regarding the nutritional status and dietary intake in patients with LC and highlight any disparities in nutritional parameters between outpatients and hospitalized LC patients.
Methods: In this prospective observational study, all consecutive LC patients attending the portal hypertension clinic and those admitted to the gastroenterology ward at Policlinico Umberto I from May 2023 to January 2024 underwent nutritional screening. Demographic information, clinical characteristics, SARC-F questionnaire, anthropometric measurements, liver frailty index (LFI) parameters, 24-hour diet recall, and food frequency questionnaire were included in the screening. Data was analyzed using Student’s t-test and chi-square test by Jamovi software version 2.3.28.

Results

Altogether 126 patients [male- 72.2%; age 63.7±10.7 years; etiology: Alcohol-53%, MASLD-19%, Viral-20%, Others-8%; MELD- 11.8±4.4; MELD Na- 13.6±5.5; 50% Child A] were enrolled. 36% of the patients were sarcopenic according to SARC-F questionnaire (score ≥ 4), with a mean LFI of 4.6±0.9. Although 65% of the patients consumed at least one protein source daily, only 15% achieved recommended daily protein intake, and 78% had lower energy intake than recommended. Of these 126 patients, 68.3% were outpatient and 31.7% were hospitalized, with comparable age and gender distribution. Hospitalized patients had a lower BMI (kg/m²) [24.7±4.1 vs 27.8±6.9; p=0.01], higher prevalence of frailty [5.1±1.1 vs 4.3±0.7; p=<0.001], lower TSF (mm) [12.4±6.8 vs 16.2±8.1; p=0.04], and lower MUAC (cm) [29.6±5.1 vs 32.2±5.6; p=0.02] than outpatients. Further, none of the hospitalized patients met adequate protein intake, contrasting with 22% of outpatients (p=0.01).

Table 1: Comparison between outpatient and hospitalized patients

Conclusion

​The impairment of nutritional status tend to increase in the more advanced stages of liver disease. There is a need for timely and routine assessment of nutritional status and implementation of targeted lifestyle interventions to optimize patient outcomes.

Introduction

Treatment targets of ulcerative colitis (UC) have evolved to include not only endoscopic but also histologic remission. However, the concept of histological activity is still in its early days. We aimed to capture the attitudes towards UC histology and the uptake of standardized reporting of endoscopy and histology of UC in daily practice.

Aims & Methods

We conducted a cross-sectional survey of physicians involved in the care of IBD worldwide. The survey included 21 questions divided into 3 sections. The first recorded demographics, specialty, and level of experience of participants; the second covered clinical practices and attitudes towards the use and reporting of endoscopy, and the third of histology.

Results

Participants: In total 359 physicians, from 60 countries (54.4% Europe, 24.4% Asia, 12.9% South America, 3.7% North America, 3.2% Africa, and 1.4% Oceania) responded; 87% were gastroenterologists, the remainder other specialists involved in the care of IBD. The majority practiced in academic hospitals (54.5%) or tertiary centers (22.1%), and only around one-fifth worked in secondary hospitals (12.8%) or local practices (8.1%).
Endoscopy: When performing endoscopy in quiescent UC, 72.1% of respondents reported taking biopsies also to assess microscopic activity, while 16.8% only for dysplasia detection, and 10.4% just in case of suspicious lesions; the average number of biopsies was 10.8 (SD 7.34, range 0 to 36). In the case of active UC, the percentage of operators collecting biopsies increased to 93.6%.
Endoscopy reports included a validated score in 91.9% of cases. Mayo was nearly always used (90%), with a large difference from the second most common score UCEIS (26.5%); other indices accounted for 1.7%. Of note, except for 1 respondent, all scores different from Mayo were used in addition to, and not instead of, Mayo. When restricting the analysis to participants working in high-volume centers (>500 UC patients cared for per year) all but one (117/118) reported using the Mayo score to grade endoscopic activity, and 32% (38/117) used also other scores in addition to Mayo, mainly UCEIS.
Histology: Centers represented in the survey were roughly equally split between those with a pathologist dedicated to IBD (46.2%) and those without (51%). UC histology was used by nearly all respondents (90.5%) for initial diagnosis, 72% to monitor disease course, 62.4% to determine microscopic extension, 59.9% to confirm deep remission when considering stopping treatment, and 42.3% to increase/optimize treatment. Nevertheless, 77.2% of participants reported that standard histological indices were not routinely available, although 21.7% of these used scores in selected cases, such as clinical trials or research. Among those who used (or worked in a center that used) standard scores (160/357) the choice of which index was mixed: 64.4% (103/160) used the Nancy index, followed by Geboes 31.9% (51/160), and Robarts 20.6% (33/160), a minority applied other scores.
The majority of respondents welcomed as useful or very useful an artificial intelligence system to automate scoring of endoscopy (69%) or histology (73%).

Conclusion

UC histology reports are less standard than endoscopy ones. Most physicians consider histological activity useful when managing UC and would welcome artificial intelligence systems to automate endoscopic and histological scoring.

Disclosure

OMN has served as a speaker for Janssen, Ferring, Takeda, Pfizer, Fresenius Kabi
MI has received research grants and equipment loans from Pentax USA, Olympus, and Fujifilm; is partially funded by NIHR Birmingham Biomedical Research Centre at the University Hospitals Birmingham NHS Foundation Trust and the University of Birmingham.
LPB reports personal fees from Galapagos, AbbVie, Janssen, Genentech, Ferring, Tillots, Celltrion, Takeda, Pfizer, Index Pharmaceuticals, Sandoz, Celgene, Biogen, Samsung Bioepis, Inotrem, Al-lergan, MSD, Roche, Arena, Gilead, Amgen, BMS, Vifor, Norgine, Mylan, Lilly, Fresenius Kabi, OSE Immunotherapeutics, Enthera, Theravance, Pandion Therapeutics, Gossamer Bio, Viatris, Thermo Fisher; grants from Abbvie, MSD, Takeda, Fresenius Kabi; stock options: CTMA.
SG has served as consultant, Steering committee member, Advisory Board Member and Drug Monitoring committee member for Janssen, Pfizer, Takeda, Abbvie, BMS, Gilead, Galapagos, Celltrion, Eli Lilly, Ferring.
SD has served as a speaker, consultant and advisory board member for Schering Plough, Abbott (AbbVie) Laboratories, Merck and Co, UCB Pharma, Ferring, Cellerix, Millenium Takeda, Nycomed, Pharmacosmos, Actelion, Alfa Wasserman, Genentech, Grunenthal, Pfizer, AstraZeneca, Novo Nordisk, Vifor and Johnson and Johnson.

Remaining authors declare no relevant conflict of interest.

Introduction

Since the report of Shaker in 1994, transnasal esophagogastroduodenoscopy (T-EGDS) has been reported worldwide as one technique to facilitate comfortable procedures avoiding sedation. From 1996 in our Centre, we routinely use this technique in all the patients for diagnostic and selected operative EGDS. This approach is also suitable for the placement of percutaneous endoscopy gastrostomy (PEG) but in the published papers it has been performed only when conventional upper gastrointestinal endoscopy was unusable (dysphagic patients with neurological disease or with stenosis and/or occlusion of the mouth or pharynx). On the contrary, since 2000 we have routinely used the transnasal approach for all patients requiring PEG, reserving the oral technique when the transnasal access route is impossible.

Aims & Methods

We performed a retrospective analysis of all patients who underwent PEG placement between January 2000 and March 2023 in the Unit of Gastroenterology of San Camillo De Lellis Hospital, Rieti, Italy, in order to demonstrate the feasibility and safety of T-PEG placement in routine practice. We used ultrathin gastroscope through a nostril after assessment and lubrification, and the pull technique was used for tube placement.

Results

PEG placement was required for 256 consecutive patients (male 49.4%; female 51.6%), the average age was 79 years, within a range from 26 to 104 years. Transnasal approach was used in 162 patients (nasal group: 63.3%) while oral approach was used in 94 (oral group: 36.7%). The failure of transnasal approach was related to impossibility of nasal intubation due to narrow nasal passages or to inability to transilluminate the stomach. In these cases we needed transoral route. 14 patients underwent transoral PEG placement due to unavailability of transnasal gastroscope. The duration of the procedures was similar in both approaches (12 ±3 minutes oral vs 13±4 minutes nasal).
The most common indications for PEG insertion were neurologic disorders (n=132, 51.6 %), cerebrovascular accident (n=73, 28.5 %), esophageal cancer or head and neck cancer (n=18, 7 %), other pathologies (n=33, 12.9 %). 167 procedures were performed without sedation: 77.8 % ( n= 130) in the nasal group and only 22.1% (n=37) in the oral group. Outpatient regimen PEG placement was also significantly higher in trans nasal group (79 % vs 58 % oral group). We registered 3 major complications, 1 in oral group and 2 in nasal group (one necessitated surgery). No procedure-related death was registered. There were no unplanned re-admissions of outpatients discharged from the gastroenterology unit for procedure-related complications.

Conclusion

The more than twenty years’ experience of our center demonstrates that the transnasal approach is safety, feasible and could be routinely used in daily endoscopic practice for PEG placement. The minimally invasive technique therefore reserves sedation to a few selected cases to reduce costs, improve logistic organization and avoid anesthesia related complications.

References

1. Campo R, Montserrat A, Brullet E. Transnasal gastroscopy compared to conventional gastroscopy: a randomized study of feasibility, safety, and tolerance. Endoscopy. 1998 Jun;30(5):448-52.
2. Schuldt AL, Kirsten H, Tuennemann J, Heindl M, van Bommel F, Feisthammel J, Hollenbach M, Hoffmeister A. Necessity of transnasal gastroscopy in routine diagnostics: a patient-centred requirement analysis. BMJ Open Gastroenterol. 2019 Apr 14;6(1):e000264.
3. Dumortier J, Lapalus MG, Pereira A, Lagarrigue JP, Chavaillon A, Ponchon T. Unsedated transnasal PEG placement. Gastrointest Endosc. 2004 Jan;59(1):54-7.
4. Dumortier J, Napoleon B, Hedelius F, Pellissier PE, Leprince E, Pujol B, Ponchon T. Unsedated transnasal EGD in daily practice: results with 1100 consecutive patients. Gastrointest Endosc. 2003 Feb;57(2):198-204
5. Preiss C, Charton JP, Schumacher B, Neuhaus H. A randomized trial of unsedated transnasal small-caliber esophagogastroduodenoscopy (EGD) versus peroral small-caliber EGD versus conventional EGD. Endoscopy. 2003 Aug;35(8):641-6.