Introduction

Adequate bowel preparation (BP) is crucial for high-quality colonoscopy surveillance in ulcerative colitis (UC), because an inadequate one leads to incomplete colonoscopy and higher rate of missing precancerous lesions, which are usually flat or subtle in this setting. There is conflicting evidence regarding whether disease activity or extension are risk factors for inadequate BP in patients with inflammatory bowel disease (IBD); furthermore, data on the optimal PEG-regimen which should be used in this setting are limited. The aim of this study was to assess which factors influence the quality of BP in this specific setting.

Aims & Methods

This is a multicentre, cross-sectional, retrospective study carry out in four referral centres between January-2021 and December-2023, including quiescent UC patients with endoscopic remission (Mayo endoscopic score=0) who underwent colonoscopy. Bowel preparation quality was assessed using the Boston Bowel Preparation Scale (BBPS) and performed with 1L-PEG-ASC (Plenvu®) and 2L-PEG (Moviprep® and Clensia®), without any specific allocation or instructions. Demographic, anamnestic and endoscopic data were evaluated and analysed.

Results

Overall, 261 UC patients (F 99, 37.9%, mean age 55.6±14.5) were recruited. Patients with previous maximum extension of proctitis (E1) were 31 (12.1%), with left-sided colitis (E2) were 104 (40.6%) and with pancolitis (E3) were 121 (47.3%); additionally, patients with a history of advanced therapy were 104 (39.8%). Entire cohort adequate preparation rate was 90.4%.
1L-PEG-ASC preparation showed significantly higher adequate BP rate compared to 2L-PEG preparations (93.7% vs 85.4%, p=0.032). Right colon adequate BP did not differ among the BPs (93.7% vs 91.3%). Patient demographics, smoking status, maximum disease extension, history of advanced therapy or presence of pseudopolyps did not significantly affect BP quality (p>0.05).

Conclusion

In a relatively unbiased setting, such as quiescent UC patients in endoscopic remission, bowel preparation volume, specifically 1L-PEG-ASC, was the primary determinant of BP quality, with neither disease extent nor a history of advanced therapy affecting BP. These findings suggest that 1L-PEG-ASC preparation may be the preferred option for colonoscopy BP in UC patients when not contraindicated.

Clinical Case Summary

A 46-year-old man from Bolivia consulted for abdominal pain with watery diarrhoea and occasional rectorrhagia for the last 2 months, associated with asthenia and weight loss. Laboratory tests showed microcytic anaemia, elevated C-reactive protein, positive faecal occult blood and negative stool culture. Colonoscopy (Images 1, 2) revealed deep ulcers in the ileum and colon with discontinuous areas of respected mucosa. Treatment was started with oral methylprednisolone at a dose of 1 mg/kg, with a decrease in the stool rhythm. He returned to the emergency department due to worsening abdominal pain, and was admitted for follow-up care. Histology (Image 3) showed epithelioid granulomas of probable infectious origin, due to the intramacrophagic inclusions, so the corticosteroid treatment was suspended. The quick test for HIV was positive, with a viral load of 79,000 copies/ml and a CD4 count of 88 CD4/ml. Mantoux and IGRA were negative. PCR amplification for Histoplasma spp in ileal biopsy was positive. Amphotericin B was prescribed with prophylaxis of opportunistic infections with trimethoprim-sulfamethoxazole. After 2 weeks, antiretroviral treatment was started. The patient improved, the abdominal pain disappeared and his intestinal rhythm normalised, and he was discharged from hospital. On outpatient follow-up, he was asymptomatic, with resolution of the ulcers in the control colonoscopy and no evidence of fungal structures in the histological examination.
The infection by Histoplasma capsulatum is the most frequent endemic mycosis in the American continent. Intestinal involvement is rare, with a preference for the ileocecal region in the form of deep ulcers that can simulate an outbreak of Crohn disease, as in our case. The use of immunosuppressants, especially anti-TNF-alpha, may worsen its course, highlighting the importance of a broad differential diagnosis, taking into account the patient's epidemiological characteristics.

References

Image 1. Colonoscopy. Terminal ileum with large ulcer with fibrin background, oedema and perilesional erythema.
Image 2. Colonoscopy. Transverse colon with two large deep ulcers with fibrin background and raised edges.
Image 3. Biopsy of ileum. Non-caseating epithelioid granulomas with intramacrophagic inclusions in ileal tissue. HE 40x.

Introduction

Sessile serrated lesions (SSLs), alongside adenomas, play a significant role in the development of colorectal cancer (CRC). Recent studies suggest that the adenoma detection rate (ADR) alone may not be sufficient for predicting post-colonoscopy CRC. Consequently, the ASGE/ACG Quality Task Force has recently recommended the sessile serrated lesion detection rate (SSLDR) as a new priority indicator for colonoscopy quality. Reviewing the variability of SSLDR in the control groups of previous randomized controlled trials (RCTs) may help identify factors that influence study outcomes.

Aims & Methods

A systematic review was conducted using PubMed, Embase, and the Cochrane Library databases to collect data from control groups of RCTs that assessed methods for increasing polyp detection with high-definition white-light colonoscopy (up to March 14, 2025). Random-effects meta-analysis pooled SSLDRs and their 95% confidence intervals (CIs). Heterogeneity was assessed with the I² statistic. Univariable and multivariable meta-regressions were performed to examine associations between SSLDR and study settings (publication year, sample size, number of centers, study design, and geographic origin), demographics (mean age, male proportion), and technical parameters (type of intervention, proportion of screening colonoscopy, ADR, and withdrawal time). This study was registered in PROSPERO (ID: CRD420251012475).

Results

A total of 23,461 patients from 48 studies were included in the analysis. SSLDR in the control arms ranged from 0.3% to 21.5%, with a pooled value of 4.4% (95% CI: 3.3%-5.8%; I² = 93%). Univariable meta-regression analysis identified patient age (OR 1.112; 95% CI: 1.043-1.186) and gender (OR 1.038; 95% CI: 1.003 to 1.074), geographic origin (OR 2.848; 95% CI: 1.585-5.116 for Europe and OR 4.044; 95% CI: 2.205-7.416 for North America), and ADR in the control arms (OR 1.054; 95% CI: 1.031-1.077) as significant predictors of SSLDR, with sample size (OR 0.999; 95% CI: 0.998-1.000) showing a negative correlation. Other factors, such as publication year, number of study centers (single or multiple), study design (parallel or tandem), type of intervention (imaging or mechanical), proportion of screening colonoscopy, and withdrawal time, had no significant effect. In multivariable meta-regression, RCTs conducted in Europe (OR 2.179; 95% CI: 1.242-3.820) and North America (OR 2.664; 95% CI: 1.550-4.580), as well as ADR in control arms (OR 1.035; 95% CI: 1.006-1.065), remained significant predictors of SSLDR, while sample size (OR 0.998; 95% CI: 0.997-0.999) and proportion of screening colonoscopy (OR 0.991; 95% CI: 0.983-0.998) were negatively correlated with SSLDR.

Conclusion

A high level of variability in SSLDR was found in the control groups of RCTs. Standardization of methodological and technical parameters is essential to improve the generalizability and reproducibility of findings from RCTs and enhance SSL detection in colonoscopy.

Introduction

Personalizing biologic therapies in inflammatory bowel disease (IBD) remains a critical unmet need. Here, we investigated circulating and stool microRNAs (miRNAs) as prognostic markers for treatment response across three biologics - anti-TNF, vedolizumab (VEDO), and ustekinumab (UST) - and explored their relationship with gut microbiome to uncover potential host-microbe predictors of response.

Aims & Methods

This study included 43 IBD patients (mean age 40.4 years, 25.6% female, 20.1% with ulcerative colitis) enrolled in the ILEITIS cohort at National University Hospital, Singapore. The majority had received anti-TNF (n=35), whilst others were given VEDO (n=9), or UST (n=15) therapies. Clinical non-response was defined as disease flare within 48 weeks post-induction, indicated by C-reactive protein >5 mg/L, fecal calprotectin >150 μg/g, or moderate to severe endoscopic inflammation. Baseline serum and stool samples were collected and isolated for miRNA profiling by the ID3EAL^TM PanoramiR microRNA Knowledge Panel (MiRXES) via the QuantStudio5-384-well qPCR system (Applied Biosystems). Fecal microbial communities were assessed via shotgun metagenomic sequencing. Differential expression analysis and Spearman correlation with false discovery rate (FDR) adjustment were performed to explore miRNA–microbe associations and treatment response patterns.

Results

Among 376 paired serum and stool miRNAs analyzed, only six exhibited significant positive correlations, indicating largely compartment-specific expression patterns. Stool miRNAs demonstrated stronger and more numerous correlations with gut microbial taxa (11 significant pairs, FDR < 0.05), whereas serum miRNAs showed no strong associations. Biologic-specific miRNA signatures were identified. Predictive modelling identified top-ranked miRNA with high discriminative performance for treatment response; serum miR-296 and stool miR-134 perfectly predicted VEDO response (AUROC = 1.0); serum miR-146 predicted UST response (AUROC = 1.0); and stool miR-302 robustly predicted anti-TNF response (AUROC = 0.897). Correlation analysis between biologic-responsive miRNA and microbial taxa revealed 12 significant correlations for stool-derived miRNA and 14 for serum-derived miRNA. Notable microbial species involved in these associations include Bacteroides uniformis, Parabacteroides distasonis, Phocaeicola dorei, Clostridium scindens, Streptococcus sanguinis, Bilophila wadsworthia, Hungatella hathewayi, and Clostridium leptum, all taxa implicated in IBD-associated dysbiosis, showed significant correlations (FDR < 0.05).

Conclusion

Stool- and serum-derived miRNAs capture non-overlapping but complementary dimensions of host response to biologic therapy in IBD. There are significant overlaps between host miRNAs and microbiome readouts suggesting plausible links between key microbial responders to therapy and host regulatory miRNAs, especially in the luminal compartment. Our findings highlight the value of integrating compartment-specific miRNA and microbiome profiling to improve precision medicine approaches in IBD.

Introduction

ESD allows en bloc resection of complex colorectal polyps. General anaesthetic (GA) for ESD is standard, requiring routine admission to hospital for monitoring. At our Trust conscious sedation is used preferentially. This study presents clinical outcomes of ESD performed in a high-volume tertiary centre in the UK using this approach.

Aims & Methods

• To evaluate the clinical outcomes of colorectal endoscopic submucosal dissection performed without general anaesthesia in a high-volume UK tertiary centre.
• To assess the feasibility and safety of ESD under conscious sedation or no sedation, with particular focus on rates of en bloc and R0 resection, adverse events, and post-procedural admissions.
• To identify clinical and procedural factors independently associated with incomplete (R1) resection following colorectal ESD.
• To compare outcomes between patients undergoing ESD with GA versus those without
Colorectal ESD procedures performed between 2018-2024 in a single centre in the UK were included. Data was retrospectively collected from the patient records. Multiple logistic regression was performed to identify independent factors associated with incomplete resection.

Results

A total of 147 patients (91 males ; median age 68 years) were included. Most polyps were rectal (100/150, 66.6%). Median polyp diameter was 42.5 mm.
GA was utilised in 13 patients, 80 had sedation alongside analgesia (median dose midazolam=2mg, fentanyl=100mcg) 44 required no IV sedation or analgesia, 8 had analgesia alone (median dose fentanyl 100mcg), 2 had sedation alone (median dose midazolam 0.75mg).
4 patients were admitted to hospital after their procedure and 14 were admitted within 30 days. There were 4 (2.7%) perforations and 7 (4.7%) post polypectomy bleeds (PPB).
Most procedures were complete ESD (109/147, 74.1%), the rest being hybrid ESD. R0 excision was achieved in 70/109 (64.2%) of those who had a complete ESD resection. No residual tissue was seen in patients with an R0 resection who had a subsequent LGI endoscopy (43/70). In those with R1 resection, a site check was undertaken at the same Trust in 59 patients. Residual tissue was seen in 7/59 (12%).
On univariate binomial regression, R1 resection was associated with polyps involving the dentate line [OR = 5.29 (95% CI = 1.84 – 17.8)], those with severe fibrosis [OR = 20.8 (95% CI = 3.85- 386.4)] and those receiving a GA [OR = 3.56 (95% CI = 1.06-16.3)]. On multivariate analysis, polyps involving the dentate line [OR = 8.17 (95% CI = 2.24 – 35.8)] and those with severe fibrosis [OR = 17.9 (95% CI = 2.57- 366.2)].

Table 1 - Outcomes of admissions following ESD

Conclusion

ESD is an effective treatment for high-risk complex colorectal polyps, able to provide high rates of en bloc resection. It can be achieved safely in most patients without GA. GA was associated with a higher rate of R1, however, this likely relates to these lesions being more complex.

Introduction

Early gastric cancer (EGC) refers to adenocarcinoma confined to the mucosa or submucosa, regardless of lymph node status. It is increasingly detected due to the widespread implementation of upper gastrointestinal endoscopy, particularly in East Asia. For intramucosal EGC (T1a), endoscopic resection such as endoscopic submucosal dissection (ESD) has been established as the standard of care, given its low risk of lymph node metastasis (LNM) and favorable long-term outcomes. However, the management of submucosal invasive EGC (T1b) remains controversial. The Japan Gastroenterological Endoscopy Society (JGES) recommends additional surgical resection with lymphadenectomy following ESD if pathological evaluation indicates T1b invasion, due to the significantly increased LNM risk. Nonetheless, many patients who undergo surgery for T1b EGC are ultimately found to be node-negative, raising concerns regarding overtreatment and its associated morbidity. This study aimed to evaluate real-world data from a tertiary center in Taiwan to clarify the necessity of additional surgical intervention after ESD in T1b cases.

Aims & Methods

This retrospective cohort study analyzed data from patients diagnosed with EGC between January 2011 and December 2022 at Kaohsiung Chang Gung Memorial Hospital. Inclusion criteria were histologically confirmed Tis, T1a, or T1b gastric adenocarcinoma treated with either ESD or surgical resection. Patients with gastrointestinal stromal tumors, neuroendocrine neoplasms, or advanced-stage disease were excluded. Depth of invasion was evaluated preoperatively using endoscopic ultrasonography (EUS), and pathological staging was confirmed on resected specimens. Patients in the ESD group with submucosal invasion (T1b) were further assessed for curative resection status based on en bloc resection, margin negativity, and absence of lymphovascular invasion. Those with non-curative ESD were referred for additional gastrectomy and lymph node dissection. LNM rates and nodal staging were analyzed based on surgical pathology.

Results

A total of 753 patients met the inclusion criteria, comprising 663 in the surgical group and 90 in the ESD group. Among those undergoing surgery, 124 patients had T1b tumors. Of these, 25 (20.1%) had pathologically confirmed LNM, the majority of which were classified as N1 disease (14/25, 56%), indicating involvement of one to two regional lymph nodes. In contrast, 3 patients in the ESD group were found to have T1b lesions on final pathology. All three underwent additional gastrectomy and lymphadenectomy despite negative margins and no lymphovascular invasion in the initial ESD specimens. None of these patients had detectable LNM post-surgery. Overall, the ESD group showed no cases of local or distant recurrence during follow-up.

Conclusion

Our 10-year institutional data suggest that approximately one in five patients with T1b EGC harbor LNM, with most cases limited to N1 involvement. While current guidelines advocate for additional surgery in T1b EGC to address potential occult metastasis, our findings suggest that in selected patients with favorable pathological features—such as negative margins, no lymphovascular invasion, and limited submucosal depth—ESD alone may be sufficient. This underscores the need for individualized risk stratification models incorporating endoscopic, histologic, and molecular factors to avoid unnecessary surgical morbidity. Prospective studies are warranted to validate such models and optimize treatment pathways for T1b gastric cancer in the era of minimally invasive therapy.

References

1. Sun W, Liu S, Zhang H, et al. Risk factors and clinicopathological characteristics of lymph node metastasis in T1b gastric cancer: A multicenter retrospective study. Cancer Med. 2022;11(11):2234–2243. doi:10.1002/cam4.4602
2. Shichijo S, Uedo N, Kanesaka T, et al. Long-term outcomes after endoscopic submucosal dissection for differentiated-type early gastric cancer that fulfilled expanded indication criteria: a prospective cohort study. J Gastroenterol Hepatol. 2020;35(1):74–81. doi:10.1111/jgh.14780
3. Zhang L, Liu H, Xu C, et al. Lymph node metastasis and prognostic analysis in early gastric cancer: a single-center experience with 1,011 cases. J Gastric Cancer. 2024;24(1):45–53. doi:10.5230/jgc.2024.24.e5
4. Kim YI, Kim CG, Lee JY, et al. Long-term outcomes of endoscopic submucosal dissection with or without additional surgery for T1b gastric cancer. Ann Surg Oncol. 2023;30(5):1234–1242. doi:10.1245/s10434-022-12600-3
5. Fang WL, Huang KH, Chen JH, et al. The risk factors of lymph node metastasis in early gastric cancer. Pathol Oncol Res. 2015;21(4):941–946. doi:10.1007/s12253-015-9920-0
6. Choi KK, Bae JM, Kim SM, et al. The risk of lymph node metastases in 3951 surgically resected mucosal gastric cancers: implications for endoscopic resection. Gastrointest Endosc. 2016;83(5):896–901. doi:10.1016/j.gie.2015.08.052

Introduction

Eosinophilic esophagitis (EoE) is a chronic, immune-mediated disease characterized by symptoms of esophageal dysfunction and eosinophilic inflammation. Dietary therapy is an effective treatment for EoE patients of any age. However, data on the clinical effectiveness of dairy free diet (DFD) in adults remain limited.

Aims & Methods

Our study aims to explore the clinical, endoscopic and histological responses to a 12-week course of a dairy-free diet in adult patients diagnosed with EoE. We conducted a real-life multicenter prospective study on adult patients with histologically active EoE. After nutritional counseling, DFD was prescribed to adult EoE patients with one of the following indications: as a first-line therapy for newly diagnosed EoE; as an add-on therapy for EoE patients who were clinical responders but histological non-responders to proton pump inhibitors (PPIs); and as a second-line therapy. Clinical assessments and quality of life were evaluated using EEsAI, I-SEE, and the EOE-QOL-A scores at baseline and after 12 weeks of DFD. Adherence to DFD was assessed using VAS scale. Esofagogastroduodenoscopy with biopsies was repeated after 12 weeks for endoscopic and histological assessments.

Results

Twenty-one adult EoE patients undergoing DFD at 5 Italian Centers were enrolled from October 2022 to June 2024. Baseline characteristics of patients are described in Table 1. After 12 weeks of DFD, 50% of patients were histological responders and, among them, 90% were also clinical responders to DFD. Histological responders to DFD showed a significant reduction in both EEsAI and ISEE scores (p=0.01) compared to non-responders. Median EoE-QoL-A score significantly improved independently from response to therapy. Patients with both clinical and histological response showed higher adherence score measured by VAS scale compared to the other patients (p=0.02). No factors were predictive of adherence to DFD therapy.

Table 1.Baseline characteristics

Conclusion

DFD can be offered as an effective therapy for adult EoE patients and significantly improves quality of life.