Introduction

Common variable immunodeficiency (CVID) is the most prevalent primary immune deficiency. Two-thirds of CVID patients present concomitant autoimmune disorders, including gastrointestinal autoimmune disease, other than being at risk for gastric cancer.

Aims & Methods

We aimed to assess the prevalence of autoimmune gastrointestinal manifestation in patients with CVID and to evaluate the diagnostic yield of EGDS for the screening of gastric pre-neoplastic lesions in a prospective cohort of patients with CVID. From June 2020 to June 2022, we prospectively enrolled patients with CVID diagnoses from a tertiary referral center. At enrollment, patients underwent a gastroenterological screening consisting of clinical evaluation and laboratory tests for the screening of autoimmune gastrointestinal disease. Moreover, all patients were proposed to undergo an esophagogastroduodenoscopy (EGD) regardless of the presence of GI symptoms to rule out pre-neoplastic gastric lesions and upper gastrointestinal disease in the presence of clinical suspicion. Patients with lower GI symptoms were proposed for colonoscopy.

Results

We included 94 patients with CVID, of whom 58 (61.7%) were females, with a mean age of 44.3 years old [standard deviation (SD) 16.3]. Overall, 12 patients (12.8%) were diagnosed with one or more gastrointestinal autoimmune diseases. Eight patients (8.5%) had ongoing therapy with intravenous immunoglobulin, while 24 (25.5%) with subcutaneous immunoglobulin. Four patients (4.3%) had a previous celiac disease diagnosis, with a negative serology at screening, and only 1 (1.1%) patient had evidence of villous atrophy and duodenal inflammation at the time of EGD. Three (3.2%) patients were diagnosed with autoimmune atrophic gastritis with negative serology and evidence at biopsies taken during EGD of atrophic gastritis. One patient (1.1%) was diagnosed with ulcerative colitis, one patient (1.1%) with Crohn’s disease, and 5 patients (5.3%) with autoimmune hepatitis. Sixteen (16, 17%) patients reported inhalant allergy, 5 (5.3%) reported food allergy, and 26 (27.7%) reported drug-related allergy. Eleven (11.7) patients reported previous Helicobacter pylori (HP) infection, while only 1 (1.1%) patient was diagnosed with an ongoing HP infection. Fifty-eight patients underwent EGD, with endoscopic evidence of esophagitis in 8 patients (13.8%), gastritis in 45 (77.6%), and duodenal atrophy/inflammation in 23 (39.7%), of whom 41.4% had histological evidence of duodenal lymphocytosis. No patient was diagnosed with gastric cancer. Twenty-three patients underwent colonoscopy according to clinical indication, which showed at biopsy sampling ileal nodular follicular hyperplasia in 2 patients (8.7%), microscopic (lymphocytic) colitis in 2 patients (8.7%), ulcerative colitis in 1 (4.3%) and Crohn's disease in 1 (4.3%).

Conclusion

Celiac disease, atrophic gastritis, and autoimmune hepatitis were the most common gastrointestinal autoimmune overlaps of patients with CVID. Autoimmune gastrointestinal diseases in patients with CVID may pose a particular diagnostic challenge since autoantibodies are often absent. Five percent of CVID patients screened with EGD was found with a gastric pre-neoplastic lesion. Further data are needed to define the optimal timing of endoscopic follow-up of these patients for the screening of pre-neoplastic and neoplastic lesions.

Disclosure

Served as an advisory board member for EG Pharma
Received lecture grants from AlfaSigma, Bromatech, Echosens, Ferring, Mayoly Spindler and Schwabe Pharma.

Introduction

Approximately 15-19% of patients suffering from irritable bowel syndrome (IBS) have an eating disorder (ED) based on a screening score or dietary assessment (1). Avoidant/restrictive food intake disorder (ARFID), a long-recognised eating disorder in children, is now recognised in adults. In a Swedish study, 13.2% of patients suffering from IBS reported severe dietary avoidance or restriction, suggestive of ARFID (2). A screening questionnaire for this disorder has recently been validated in French (NIAS-Fr, for Nine Item ARFID Screen in French) (3).

Aims & Methods

This study aims to assess the prevalence of ARFID in IBS in France, by comparing the NIAS-Fr questionnaire and the assessment by a specialised dietitian, and to look for links between its presence and the clinical phenotype of patients. This study was conducted between February and September 2024 in consecutive patients suffering from IBS and evaluated in a multidisciplinary day hospital structure. Clinical characteristics (age, gender, BMI, IBS subtype and its severity [IBS-SSS], presence of functional dyspepsia, diet and disease duration) and presence of ARFID (clinically or one abnormal NIAS-Fr subscale) were collected. A dietitian assessed the presence of “clinical ARFID”. The NIAS subscales allow for the diagnosis of patients as “picky eaters” (score ≥10), with “poor appetite” (score ≥9) and/or with a “fear of eating” (score ≥10). Patients with a history of ED diagnosed by a psychiatrist and/or an abnormal ED screening score (SCOFF ≥ 3 and/or global EDE-Q8 ≥ 4.0) were excluded from the analysis.

Results

Of the 95 patients with IBS according to Rome IV, 55 (57.9%) had at least one positive NIAS-Fr subscale, with 10 (10.5%) having an abnormal “picky eater” subscale, 16 (16.8%) an abnormal “poor appetite” subscale, and 49 (51.6%) an abnormal “fear of eating” subscale. Of these 95 patients, 15 were excluded from the analysis because of a history of eating disorders or an abnormal screening score. We therefore included 80 patients for analysis (77.5% women; mean age 48.5 ± 16.8 years, BMI 22.6 ± 4.6 kg/m²; 40.0% IBS-D, 38.8% IBS-C, and 20.0% IBS-M; 51.3% had associated dyspepsia; 62.5% were on a special diet at the time of assessment). The mean IBS-SSS score was 319.5 ± 88.2 points (severe forms in 61.2%). Among these 80 patients, 43 (53.8%) had at least one positive NIAS-Fr subscale, including 10.0% of "picky eaters," 16.3% of "poor appetite," and 48.8% of "fear of eating." Patients with at least one positive NIAS-Fr subscale had more frequent functional dyspepsia than those with a negative NIAS (65.1 vs. 35.1%, p = 0.013), but there were no differences in the other parameters assessed. According to the dietitian's assessment, 19 (23.8%) patients in our cohort had clinical ARFID, i.e., 44.2% of those with at least one positive NIAS-Fr subscale. In an IBS population, the specificity of the NIAS-Fr questionnaire for diagnosing clinical ARFID was 55.8% (95% CI: 41.1-69.6). None of the assessed parameters distinguished patients with and without clinical ARFID (p > 0.05).

Conclusion

ARFID symptoms are found in more than half of IBS patients treated in a tertiary care centre based on an abnormal NIAS-Fr screening questionnaire, after excluding other eating disorders. These patients frequently have associated functional dyspepsia and a normal BMI. Based on a dietary assessment, clinical ARFID is found in approximately one-quarter of IBS patients. The specificity of the NIAS-Fr in IBS is too low to allow a diagnosis of ARFID in this population.

References

(1) Wuestenberghs et coll. Intérêt du dépistage des troubles du comportement alimentaire au cours du syndrome de l’intestin irritable. JFHOD 2024 (number 000694)
(2) Melchior et coll. Food Avoidance and Restriction in Irritable Bowel Syndrome: Relevance for Symptoms, Quality of Life and Nutrient Intake. Clin Gastroenterol Hepatol. 2022;20(6):1290-1298.e4.
(3) Van Ouytsel et coll. Translation of the nine item avoidant/restrictive food intake disorder screen (NIAS) questionnaire in French (NIAS-Fr). Neurogastroenterology & Motility 2024 ; 36 (4) : e14757.

Disclosure

Nothing to disclose.

Introduction

IBS patients are often high healthcare utilizers. Symptom frequency, as well as psychological factors like neuroticism, anxiety, and depression, impact healthcare seeking. Bothersomeness, i.e., how distressing or disruptive symptoms are to a person’s daily life, is a potential treatment-seeking motivator in IBS. We aimed to evaluate symptom bothersomeness in IBS and its potential influence on healthcare utilization.

Aims & Methods

Adults in 9 countries (Canada, China, Germany, Japan, Mexico, Poland, Romania, Spain, United States) completed an online survey that included IBS Rome IV Diagnostic Questions, lifetime healthcare utilization (HCU) for IBS (Yes/No); depression and anxiety; negative emotionality/neuroticism (NE), or a person’s tendency to experience anxiety, anger, frustration, pessimism, or depressed mood; demographic questions and the question “Is the [symptom] bothersome to you?” (yes/no) for each: abdominal pain, hard/lumpy stools, and soft/mushy stools. Three separate binary logistic regression models assessed the symptom's frequency, depression, anxiety, NE, sex, and age as predictors of bothersomeness for each of the key IBS symptoms. Three additional regression models evaluated each symptom's bothersomeness and frequency, depression, anxiety, NE, sex, and age as predictors of HCU.

Results

Of 17,663 participants, 1,389 (7.9%) met Rome IV criteria for IBS (mean age 41.6 (SD 14.7) years, 62.3% female; IBS sub-types: 32% C, 29% D, 36% M, 4% U). Of those with IBS, 65.7% had ever visited a doctor because of bowel problems. Abdominal pain was rated bothersome by 93% of people with IBS, hard stools by 80%, and mushy/watery stools by 78%, with no sex differences. Older people (ages 65+) reported only hard stools as more bothersome (t(1236) = -3.40, 95%CI: -5.54 to -1.49, p<.001) than people of ages 18-39 or 40-64. Bothersomeness (yes/no) was predicted in regression analyses by higher frequencies of abdominal pain [Odds Ratio (OR) and 95% CI: 2.00 (1.46-2.74)], hard stools [1.33 (1.24-1.43)], and mushy stools [(1.24 (1.16-1.31)], but not by age, sex, or psychological variables. People with IBS were significantly more likely (χ²) to have ever visited a doctor for bowel problems if they rated their pain (p = .003), hard stools (p = .020), and mushy stools (p < .001), as bothersome. Finding pain and mushy stools bothersome (yes/no) increased the odds of HCU for pain and mushy stools, but not for hard stools in the regression models (Table 1). Higher frequency of pain and hard stools (but not mushy stools) also increased HCU odds, and older people were more likely to consult for all 3 symptoms. Psychological variables and sex were not significant predictors of HCU.

Table 1. Binary regression analyses for predicting IBS lifetime doctor consulting for bowel symptoms

Conclusion

For persons with IBS, subjective experience of how bothersome symptoms are is strongly associated with symptom reporting and a driving factor to HCU regardless of gender, psychological distress, or negative emotionality. Providers need to assess symptom bothersomeness in their clinical decision-making.

Introduction

Endoscopic ultrasonography-guided gastroenterostomy (EUS-GE) is emerging as a new and minimally invasive endoscopic treatment method for gastric outlet obstruction (GOO). In EUS-GE, it is important that stents can be safely and reliably deployed and that there is no stent migration. As the optimal method, we have developed the EUS-guided balloon-occluded gastrojejunostomy bypass (EPASS) and have performed it as a clinical study.

Aims & Methods

We retrospectively evaluated the results of EPASS including long-term outcomes. The EPASS procedure was performed under conscious sedation. The endoscope was used to reach the site of obstruction. The stricture was cannulated with a 0.025-inch guidewire and the guidewire was used to negotiate beyond the site of obstruction under endoscopic and fluoroscopic guidance. The double balloon tube was then inserted on the guidewire beyond the duodenal–jejunal flexure using an overtube. The two balloons of the occluder were inflated with 30–40 mL normal saline and constrast. 200–300 mL of methyleneblue-stained saline was then injected to distend the occluded segment of duodenum. A linear echoendoscope was then inserted into the stomach. A site in the posterior wall of the body of the stomach was punctured directly by the delivery system of the lumen apposing metal stent. A 20 x 10 or 15 x 10 mm stent was used. The distal flange of the stent was deployed under EUS guidance, followed by deployment of the proximal flange under endoscopic or EUS guidance. Stent position was confirmed with the drainage of methylene-blue-stained saline, the endoscopic view of the proximal flange and also the fluoroscopic image. Thirty-six consecutive patients with symptomatic GOO who were not refractory to surgical gastrojejunostomy were enrolled in the study. The primary endpoint was technical success rate. Secondary endpoints included procedure time, GOO scoring system (GOOSS) scores at 7 days and 1 month after EPASS, clinical success rate (improvement in GOOSS scores at 7 days after EPASS), procedure-related adverse events (AEs) rate, overall survival (OS) after EPASS in the 23 patients with long-term follow-up, and stent patency rate.

Results

The mean age was 70.6 years (range 47-91), 16 (44%) were female, and the underlying diseases were 18 pancreatic cancer, 9 gastric cancer, 3 duodenal cancer, 4 gallbladder cancer, 1 breast cancer, and 1 chondrosarcoma. The technical success rate was 94.4% (34/36), mean procedure time was 26.9 minutes (range 14-40), mean time to double-balloon tube insertion was 9.8 minutes (range 6-28), mean pre-GOOSS score was 0.42, mean GOOSS score was 2.08 and 2.21 at 7 days and 1 month after EPASS, and the clinical success rate was 88.9% (32/36). The incidence of procedure-related AE was 16.7% (6/36), including 2 cases of fever, 2 cases of abdominal pain, and 2 cases of worsening ascites. The mean overall survival after EPASS was 183.8 days, all patients died of primary disease, and there were no events such as stent occlusion or stent deviation (stent patency was 100%).

Conclusion

EPASS is a safe and reliable EUS-GE method and may be a useful treatment for symptomatic malignant GOO.

References

(1) Tsuchiya T, et al. Tech Innov Gastrointest Endosc. 2020;22:27-32.
(2) Itoi T, et al. J Hepatobiliary Pancreat Sci. 2020;27:791-792.
(3) Itoi T, et al. Gut 2016;65:193-5

Disclosure

Lecture fee : Boston Scientific Japan, Olympus Japan