Introduction

Pancreatitis remains a leading cause of hospitalization in gastroenterology. Although approximately 80% of patients exhibit a mild course, severe acute pancreatitis is associated with a mortality rate of up to 35%. The significance of thromboembolic events has come to attention lately. Incidences of splanchnic vein thrombosis (SVT) vary between 7% and 27%, while data on other events, (i.e. deep vein thrombosis (DVT)), are sparse¹. Moreover, outcome and management strategies for these complications are not established². This study emphasizes the need for further investigation into thromboembolic risks in pancreatitis to enhance prognostic and therapeutic approaches.

Aims & Methods

Prophylactic anticoagulation is frequently withheld in patients with pancreatitis, particularly for endoscopic interventions, and robust data guiding the management of established thrombosis remain scarce. This study aimed to identify risk and modulation factors associated with thromboembolic events in pancreatitis, with the goal of establishing hypothesis-driven strategies for prevention and management. We performed a retrospective cohort study at the LMU Klinikum Munich, a referral center for pancreatic diseases, including patients with acute and acute-on-chronic pancreatitis. Data collection spanned from 01/2018 to 07/2023 and comprised detailed laboratory values, vital signs, imaging and interventional procedures. This comprehensive dataset enabled an in-depth analysis of the factors influencing thromboembolic complications.

Results

A total of 647 patients were analyzed, with 14.2% (n = 92) experiencing thromboembolic events. The incidence was comparable between individuals with acute pancreatitis (15.2%) and those with acute-on-chronic pancreatitis (13.9%). Among thromboembolic complications, DVT was most prevalent (6.9%), followed by pulmonary embolism (4.8%), portal vein thrombosis (4.4%), and SVT (4.2%). Patients developing thrombosis had significantly longer hospital stays (12.5 days vs. 6 days on average), higher severity of disease (severe pancreatitis 19.6% vs. 5.7%) and more frequent as well as advanced analgesic requirements.
Baseline clinical evaluation revealed lower diastolic blood pressure and oxygen saturation, along with impaired mental status (as indicated by reduced Glasgow Coma Scale scores) in the thrombosis group. Additionally, symptoms such as fever, cough, hematemesis, and dyspnea were more commonly reported. The presence of thromboembolic events was associated with an increased incidence of local complications, including walled-off pancreatic necrosis, acute kidney injury, pleural effusion, infection, septic shock, and bleeding. Consequently, these patients more often required medications such as proton pump inhibitors and diuretics. Mortality was significantly elevated in the thrombosis group (10.9% compared to 2.0%). Among those diagnosed with thrombosis, complete resolution was observed in 51.2% of patients with acute pancreatitis and 58.3% with chronic pancreatitis, with no significant difference between the two groups. Detailed analyses of complete laboratory parameters and vital sign trends during hospitalization are presently pending, with results to be presented at UEG Week.

Conclusion

Thromboembolic events are frequently observed in patients with acute and chronic pancreatitis, potentially underdiagnosed and drivers of elevated mortality and morbidity. Although no single symptom reliably indicated the presence of thrombosis, patients with more severe disease at baseline exhibit a higher risk for these events and should undergo comprehensive evaluation.

References

1. Chung, W.-S. & Lin, C.-L. Comorbid risks of deep vein thrombosis and pulmonary
thromboembolism in patients with chronic pancreatitis: a nationwide cohort study. J. Thromb.
Haemost. JTH 14, 98–104 (2016)
2. Sissingh, N. J. et al. Therapeutic anticoagulation for splanchnic vein thrombosis in
acute pancreatitis: A systematic review and meta-analysis. Pancreatol. Off. J. Int. Assoc.
Pancreatol. IAP Al 22, 235–243 (2022).

Introduction

Cognitive Behavioral Therapy (CBT) is an evidence-based treatment for Irritable Bowel Syndrome (IBS), demonstrating long-term improvements in symptoms and quality of life (QOL). However, its implementation is hindered by the complexity of treatment protocols, high time and financial costs, and limited accessibility in Japan.

Aims & Methods

This study aimed to develop a smartphone-based CBT application and evaluate its effectiveness in alleviating IBS symptoms.
Adults aged 18 or older who met the Rome IV criteria for IBS and scored ≥110 on the Japanese version of the IBS Symptom Severity Index (IBSSI-J) were enrolled. Twenty-six participants were randomly assigned to either the intervention group (n = 14) or the waiting-list control group (n = 12). Outcome measures included the IBSSI-J, Japanese versions of the IBS-QOL (IBS-QOL-J), Pain Catastrophizing Scale (PCS-J), and Visceral Sensitivity Index (VSI-J). A two-way ANOVA was conducted with group (intervention vs. control) and time (pre, mid, post, follow-up 1) as independent variables.
The intervention group used the app for 5–10 minutes daily over two months. The app included three components: psychoeducation, cognitive restructuring, and exposure. Psychoeducation consisted of educational materials and follow-up quizzes. Cognitive restructuring used gamified multiple-choice content (135 items), replacing conventional thought records. Exposure involved users creating individual anxiety hierarchies and recording their thoughts before and after exercises. The app visualized anxiety changes and progress via graphs.

Table 1.
Intervention module of the application

Results

Eleven participants in the intervention group and eight in the control group completed the program. Significant group × time interactions were observed for all outcome measures. For the IBSSI-J, the interaction was significant (F(3, 51) = 4.41, p < .001), with the intervention group showing greater improvement at mid-point (F(1, 17) = 5.54, p = .03, η² = .25). For the IBS-QOL-J, a significant interaction was found (F(3, 51) = 8.00, p < .001), with improvement evident at follow-up 1 (F(1, 17) = 6.65, p = .02, η² = .28). For the PCS-J, the interaction was significant (F(3, 51) = 3.83, p = .02), with improvements at post (F(1, 17) = 9.26, p = .01, η² = .35) and follow-up 1 (F(1, 17) = 5.83, p = .03, η² = .26). For the VSI-J, the interaction also reached significance (F(3, 51) = 3.32, p = .05).

Conclusion

The CBT-based app was effective in reducing IBS symptom severity. Its effects persisted after the intervention and extended to improvements in QOL, visceral anxiety, and pain catastrophizing—psychological factors associated with the maintenance and exacerbation of IBS. It is assumed that the cognitive restructuring component of the app facilitated cognitive diversification among participants. By empirically challenging the plausibility of these diversified cognitions through behavioral experiments in the form of exposure tasks, participants were able to further develop more adaptive thoughts. This process is considered to have contributed to the improvement of symptoms and enhancement of QOL. This digital approach may offer a viable solution to current barriers in CBT access.

Introduction

Current therapeutic strategies for inflammatory bowel disease (IBD) remain limited, with clinical efficacy often falling short of expectations. Post-translational modifications play a pivotal role in IBD pathogenesis. This study aims to elucidate the functional significance of ubiquitination in IBD development and progression.

Aims & Methods

By analyzing colon RNA sequencing (RNA-seq) data from healthy and dextran sulfate sodium (DSS)-induced colitis mice, combined with RNA-seq datasets from healthy individuals and ulcerative colitis (UC) patients, we identified differential RNA expression levels of ATDC between healthy and inflammatory groups. Single-cell RNA sequencing (scRNA-seq) analysis further pinpointed the primary cell types exhibiting ATDC expression discrepancies. These findings were validated through immunohistochemistry, immunofluorescence, and western blot. Co-immunoprecipitation (Co-IP) assays and molecular docking simulations were employed to confirm and model the interaction between ATDC and PRMT5 in vitro. The role of ATDC in IBD pathogenesis was investigated using an ATDC-knockout (ATDC-KO) murine DSS model, with flow cytometry analyses delineating its impact on immune status.

Results

RNA-seq analysis revealed elevated ATDC mRNA levels in DSS-treated mice and UC patient intestinal tissues. scRNA-seq data indicated ATDC upregulation predominantly in the intestinal epithelial cells of UC patients. Protein-level upregulation of ATDC was further confirmed in both DSS mice and UC patient specimens. Lipopolysaccharide stimulation increased ATDC expression in Caco2 cells. Overexpression of ATDC in Caco2 cells, coupled with mass spectrometry, identified ATDC-PRMT5 binding, which was corroborated by Co-IP assays and molecular docking simulations. ATDC overexpression downregulated PRMT5 protein (but not mRNA) levels. In DSS models, PRMT5 expression was reduced compared to healthy controls; however, ATDC-KO mice exhibited PRMT5 upregulation and exacerbated colitis severity. Flow cytometry demonstrated an elevated Th17 cell proportion in ATDC-KO DSS mice relative to wild-type counterparts.

Conclusion

This study is the first to demonstrate the protective role of ATDC in colitis. ATDC attenuates colonic inflammation by promoting the degradation of PRMT5, thereby suppressing Th17 cell-mediated immune responses. Enhancing ATDC activity may represent a novel therapeutic strategy for mitigating colitis progression.

References

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Introduction

In recent years, both the incidence and early-stage diagnosis of pancreatic neuroendocrine tumors (pNETs) have increased, likely due to advancements in cross-sectional imaging techniques (1). Management strategies are size-dependent, with observation generally preferred for lesions <10 mm and surgical resection for those >20 mm. However, there is no consensus regarding the optimal approach for tumors between 10 and 20 mm, highlighting the need for multidisciplinary decision-making (2). In this setting, endoscopic ultrasound (EUS) with fine-needle aspiration (FNA) or fine-needle biopsy (FNB) plays a crucial role not only in diagnosis but also in tumor grading (3). However, samples obtained through EUS-FNA or FNB may not provide sufficient histological material to determine tumor grade in pNETs smaller than 20 mm. This study aims to summarize the current evidence regarding the adequacy of histological samples obtained via EUS-FNA/FNB for tumor grading.

Aims & Methods

This study followed the PRISMA guidelines for Systematic Reviews and Meta-Analyses. MEDLINE, EMBASE, and SCOPUS databases were searched up to December 2024 for studies reporting on the sample adequacy of EUS-FNA or FNB for grading pNETs ≤ 20 mm. Sample adequacy was defined as the proportion of samples in which the Ki-67 index was successfully obtained for tumor grading among all samples collected. Pooled estimates were calculated using random-effects models. Heterogeneity was assessed using the I² statistic. Subgroup analyses were conducted based on needle type (FNA vs. FNB).

Results

17 studies were included, analyzing a total of 1414 patients. The pooled adequacy rate was 71.6% (95% CI: 0.592–0.841), with substantial heterogeneity across studies (I² = 98.69%). The risk of publication bias was considered low based on Egger’s test (p = 0.162). When considering only studies that used FNA, adequacy rates were lower, with a pooled estimate of 52.5% (95% CI: 0.302–0.748; I² = 97.99%). In contrast, studies employing FNB showed higher adequacy rates, with a pooled estimate of 79.8% (95% CI: 0.605–0.991), although heterogeneity remained high (I² = 87.32%). In this subgroup, there was also evidence of publication bias, as suggested by Egger’s test (p = 0.017) and visual asymmetry in the funnel plot.

Conclusion

Our study found that EUS-FNA/FNB provides adequate histological specimens for tumor grading in pNETs < 20 mm, although significant heterogeneity was observed. As expected, FNB demonstrated considerably better performance than FNA in establishing tumor grade, suggesting it should be preferred for pNET sampling. However, even with FNB, tumor grade could not be determined in up to 20% of cases, indicating that it remains a suboptimal tool for grading and may offer limited additional value beyond diagnostic confirmation in some patients. Notably, our study did not distinguish between first-, second-, and third-generation FNB needles; therefore, results from newer-generation FNBs may show improved sample adequacy rates. Furthermore, the observed heterogeneity highlights the need for studies specifically evaluating the ability of EUS-FNB to obtain high-quality tissue for grading, thereby supporting the role of EUS in clinical decision-making for these small tumors.

References

1. Souche R, Hobeika C, Hain E, et al. Surgical Management of Neuroendocrine Tumours of the Pancreas. J Clin Med 2020;9.
2. Mansour JC, Chavin K, Morris-Stiff G, et al. Management of asymptomatic, well-differentiated PNETs: results of the Delphi consensus process of the Americas Hepato-Pancreato-Biliary Association. HPB (Oxford) 2019;21:515-523.
3. Franchellucci G, Andreozzi M, Carrara S, et al. Contrast Enhanced EUS for Predicting Solid Pancreatic Neuroendocrine Tumor Grade and Aggressiveness. Diagnostics (Basel) 2023;13.

Introduction

Endoscopic scores are crucial for assessing Crohn's disease (CD) severity, guiding therapy, and monitoring progression. The Simplified Endoscopic Score for Crohn's Disease (SES-CD) is widely used for this purpose [1]. Accurate scoring is vital for patient care. Recently, artificial intelligence has demonstrated potential in medical image interpretation [2]. This study aims to evaluate ChatGPT's effectiveness in rating the SES-CD.

Aims & Methods

This retrospective study evaluated ChatGPT's accuracy in assessing CD endoscopic activity using the SES-CD. One representative still image was selected for each bowel segment, and stricture degrees were provided separately if present. ChatGPT scored the SES-CD based on these images. The IBD expert's ratings were validated by calculating the intra-class correlation coefficient (ICC) with clinical trial central readers. The ICC between the IBD expert and ChatGPT scores was calculated to determine ChatGPT's reliability in SES-CD scoring.

Results

Nine (mean age 32.0 ± 11.8 years, 77.8% male) were included, with 45 bowel segments. Three (33.4%), 5 (55.6%), and 1 (11.1%) had nonstricturing nonpenetrating, structuring, and penetrating disease, respectively. Four (44.4%) had ileal disease and 5 (55.6%) had ileocolonic disease. Five (55.6%) had previous IBD surgery.
The SES-CD scores of the participants, rated by IBD expert in the hospital, revealed the following mean and standard deviation for each segment of the bowel: 6.9 ± 2.3 in the ileum, 1.3 ± 2.6 in the right colon, 1.6 ± 2.4 in the transverse colon, 1.3 ± 2.6 in the left colon, and 1.3 ± 2.6 in the rectum. The total SES-CD score was 12.4 ± 10.9. The score reliability of the institute IBD expert was tested compared to the clinical trial central reader and an intraclass correlation coefficient was calculated and found to be 0.96 (95% CI, 0.84-0.99) which is considered extremely correlated.
The mean and standard deviation of ChatGPT score in each segment were: 6.4 ± 2.4 in the ileum, 2.4 ± 3.8 in the right colon, 0.9 ± 2.7 in the transverse colon, 0.3 ± 1.0 in the left colon, 0.6 ± 1.3 in the rectum, with total SES-CD score of 10.6 ± 6.8. The calculated ICC between the expert and ChatGPT obtained SES-CD scores was 0.80 (95% IC, 0.64- 0.89) which is considered highly correlated.

Conclusion

Despite being based on only one photo per segment, ChatGPT demonstrated satisfactory performance in estimating endoscopic activity in CD. The differences between the IBD expert obtained scores and ChatGPT scores were acceptable, suggesting that artificial intelligence has the potential to be a useful tool in clinical and research settings, providing an accurate estimation of disease severity based on limited visual data.

References

1- Daperno M, D'Haens G, Van Assche G, et al. Development and validation of a new, simplified endoscopic activity score for Crohn's disease: the SES-CD. Gastrointest Endosc. 2004;60(4):505-512.
2- Levartovsky A, Albshesh A, Grinman A, et al. Enhancing diagnostics: ChatGPT-4 performance in ulcerative colitis endoscopic assessment. Endosc Int Open. 2025;13:a25420943. Published 2025 Mar 14.

Clinical Case Summary

Endoscopic ultrasound (EUS) is currently the diagnostic cornerstone for pancreatic lesions. However, its intraoperative use remains rarely documented and limited to unplanned, ad-hoc scenarios. We present a novel case series in which intraoperative EUS was systematically planned and executed as part of pancreatic tumor surgery.
Case 1: A 35-year-old male with hyperinsulinemic hypoglycemia and inconclusive imaging. EUS identified a 5 mm lesion in the pancreatic head. Intraoperative EUS confirmed its location and ruled out other lesions, enabling a focused pancreatoduodenectomy and minimizing unnecessary resection.
Case 2: A 54-year-old female with a branch-duct IPMN and mural nodule. Intraoperative EUS confirmed multiple cysts and precisely localized the dominant lesion, allowing real-time adjustment of the resection plane during laparoscopic subtotal pancreatectomy.
Case 3: A 69-year-old male with polycystic pancreas and suspected NET. Intraoperative EUS validated two lesions and clarified their anatomical relation to critical vessels, enabling a targeted, vessel-sparing Whipple procedure.
Case 4: A 77-year-old female with a glucagon-producing NET not identifiable through inspection or palpation. EUS intraoperatively localized the lesion and delineated margins, ensuring oncological completeness and parenchymal preservation.
In all cases, the same endoscopist performed both diagnostic and intraoperative EUS. This strategy enhanced surgical precision, reduced operative ambiguity, and was seamlessly integrated into the surgical workflow. To our knowledge, this is the first reported case series of prospectively planned intraoperative EUS applied across diverse pancreatic tumors. This approach demonstrates a reproducible model for interdisciplinary collaboration between surgeons and endoscopists as well as real-time surgical decision-making in high-complexity settings.

References

Illustrative material
Image 1 – Preoperative EUS showing a 5 mm solid lesion (Case 1).
Image 2 – Intraoperative EUS of cystic lesions with mural nodule (Case 2).
Image 3 – Postoperative EUS of surgical specimen confirming lesion (Case 3).
Image 4 – OR setup adapted for intraoperative EUS integration (Case 4).

Introduction

Primary sclerosing cholangitis (PSC) is known to present characteristic cholangiographic findings; however, detailed observations using peroral cholangioscopy (POCS) have rarely been reported. We previously reported that POCS findings in PSC can be classified into three types: active (inflammatory), chronic (scarring), and tumorous (tumor-like). These findings may aid in the differential diagnosis of PSC and may be useful in predicting prognosis.

Aims & Methods

We aimed to analyze POCS findings in PSC in detail based on this classification and to clarify their characteristics by evaluating the frequency of each finding, their temporal changes, and comparisons with other biliary diseases.
We retrospectively reviewed 22 patients with PSC who underwent POCS between February 2018 and February 2023. For comparison, we included 19 cases of hepatolithiasis, 25 cases of cholangiocarcinoma, and 3 cases of IgG4-related sclerosing cholangitis (IgG4-SC). Twelve POCS findings were categorized into three types: active (mucosal erythema, ulcers, fibrous white exudates, irregular surface), chronic (longitudinal scarring, annular scarring, pseudodiverticula, stenosis), and tumorous (dilated vessels, tortuous vessels, friability, mass formation). In addition, we included “punched-out lesion (POL)” as an original finding. Each finding was graded on a 5-point scale (0–4) based on the extent or number of lesions, and scores were calculated for each type. We conducted three analyses: (1) correlation between cholangiographic and POCS findings in PSC, (2) temporal changes in POCS findings in PSC, and (3) comparison of POCS findings between PSC and other biliary diseases.

Results

In the first analysis, annular scarring (100%), stenosis (89%), POL (89%), and longitudinal scarring (86%) were frequently observed in PSC. Annular scarring was identified in all cases with a shaggy appearance on cholangiography, and stenosis were present in all ducts with band-like stricture. In ducts showing diverticulum-like outpouchings, longitudinal and annular scarring, pseudodiverticula, and POL were consistently seen, whereas other findings were absent. In the second analysis, active and tumorous scores varied over time even within the same case, whereas chronic scores remained stable or showed a progressive increase. A negative correlation was observed between active and chronic scores (p-value <0.001, r =-0.702). In the third analysis, chronic findings and POL were significantly more common in PSC compared to other diseases (p-value <0.001). Pseudodiverticula were seen exclusively in PSC, while dilated and tortuous vessels and friability were significantly more frequent in cholangiocarcinoma and IgG4-SC (p-value <0.001).

Conclusion

These findings suggest that the characteristic cholangiographic findings of PSC are mainly formed by chronic scarring. Diverticulum-like outpouchings reflect only fibrotic changes. Furthermore, the coexistence of inflammation and fibrosis, along with the time-dependent progression of fibrosis, is a unique feature of PSC, although active inflammation may obscure chronic findings. Finally, longitudinal scarring and POL were particularly prominent in PSC, and pseudodiverticula were highly specific to this disease, suggesting their usefulness in differential diagnosis. In conclusion, chronic findings on POCS are characteristic of PSC and may serve as a helpful tool in its diagnosis and differentiation from other biliary diseases.

References

T Fujisawa, M Ushio, S Takahashi, et al., Role of Peroral Cholangioscopy in the Diagnosis of Primary Sclerosing Cholangitis. Diagnostics (Basel), 2020. 10(5).
T Itoi, T Kamisawa, Y Igarashi, et al., The role of peroral video cholangioscopy in patients with IgG4-related sclerosing cholangitis. J Gastroenterol, 2013. 48(4): p. 504-14.
T H Karlsen, T Folseraas, D Thorburn, et al., Primary sclerosing cholangitis - a comprehensive review. J Hepatol, 2017. 67(6): p. 1298-1323.
T Nakazawa, K Notohara, S Tazuma, et al., The 2016 diagnostic criteria for primary sclerosing cholangitis. J Gastroenterol, 2017. 52(7): p. 838-844.
T Nakazawa, H Ohara, H Sano, et al., Cholangiography can discriminate sclerosing cholangitis with autoimmune pancreatitis from primary sclerosing cholangitis. Gastrointest Endosc, 2004. 60(6): p. 937-44.
H Isayama, S Tazuma, N Kokudo, et al., Clinical guidelines for primary sclerosing cholangitis 2017. J Gastroenterol, 2018. 53(9): p. 1006-1034.
W L Campbell, M S Peterson, M P Federle, et al., Using CT and cholangiography to diagnose biliary tract carcinoma complicating primary sclerosing cholangitis. AJR Am J Roentgenol, 2001. 177(5): p. 1095-100.