Clinical Case Summary

Condyloma acuminatum represents the clinical expression of epidermal infection caused by the human papillomavirus (HPV) one of the most common sexually transmitted diseases. These lesions range from benign papules to potential precursors of anal squamous cell invasive carcinoma.
Conventional treatments include surgical excision, cryotherapy, immunotherapy and CO₂ laser ablation.Endoscopic approaches such as radiofrequency ablation (RFA) and argon plasma coagulation (APC) are emerging as therapeutic alternatives with promising efficacy and safety profiles.
We report the case of a 49-year-old woman with no relevant medical or surgical history presented with rectal bleeding. Colonoscopy revealed a flat, polypoid lesion circumferentially involving approximately 3–4 cm of distal rectum (Fig1). Biopsy confirmed HPV-6–related condyloma. She underwent transanal minimally invasive surgery (TAMIS) in 2023.
One year later, symptoms recurred. Colonoscopy showed a similar lesion now extending over more than 5 cm of the lower rectum (Fig2-3).Given the lesion's recurrence, extensive involvement, and challenging location, endoscopic RFA was selected as the treatment modality. Using a HALO90° catheter (BARRX Medical Inc.) introduced through a flexible colonoscope, high-energy pulses (1000 pulses at 15 Joules per pulse) were applied to the affected mucosa, achieving near-complete ablation. Residual lesions and the anal canal were subsequently treated with APC (AXIAL catheter, 0.8 L/min, 30 W)(Fig4). The procedure was completed on an outpatient basis without immediate complications.
Post-procedurally, the patient reported transient anal pain and mild bleeding. At 3-month follow-up, mucosal healing was adequate (Fig5), with minor residual lesions successfully treated with APC (Fig6).
This case highlights the utility of combined endoscopic RFA and APC in managing extensive, recurrent rectal condyloma refractory to surgery reducing morbidity and preserving anorectal function.

References

1. Mark Schiffman, Susanne Krüger Kjaer, Chapter 2: Natural History of Anogenital Human Papillomavirus Infection and Neoplasia, JNCI Monographs, Volume 2003, Issue 31, June 2003, Pages 14-19, https://doi.org/10.1093/oxfordjournals.jncimonographs.a003476
2. Ramamoorthy S, Liu YT, Luo L, Miyai K, Lu Q, CarethersJM:Detection of multiple human papillomavirus genotypes in analcarcinoma. Infect Agent Cancer, 2010; 5:17.
3. Wiley DJ, Douglas J, Beutner K, et al.:External genital warts:Diagnosis, treatment, and prevention. Clin Infect Dis, 2002; 35(Suppl 2), S210-24.
4. Goldstone, R.N., Hasan, S.R., Drury, S. et al. A trial of radiofrequency ablation for anal intraepithelial neoplasia. Int J Colorectal Dis 32, 357–365 (2017). https://doi.org/10.1007/s00384-016-2679-2
5. Goldstone, R. N., Hasan, S. R., & Goldstone, S. E. (2017). Brief report: radiofrequency ablation therapy for anal intraepithelial neoplasia: results from a single-center prospective pilot study in HIV+ participants. JAIDS Journal of Acquired Immune Deficiency Syndromes, 76(4), e93-e97.
6. Smulian, A. G., Moore, D. M., Robertson, J. C., & Kralovic, S. M. (2014). Phase I Study Demonstrates Safety and Tolerability of Radiofrequency Ablation (RFA) of the Anal Mucosa. HIV Clinical Trials, 15(1), 36–44. https://doi.org/10.1310/hct1501-36.
7. Bulsiewicz WJ, Shaheen NJ. The role of radiofrequency ablation in the management of Barrett’s esophagus. Gastrointest Endosc Clin N Am 2011; 21: 95-109.

Introduction

Sex-based differences in clinical outcomes are increasingly being recognised in acute care, yet few studies have examined whether upper gastrointestinal bleeding (UGIB) risk scores perform differently in male versus female patients. This study evaluated the discriminatory performance of five established UGIB risk scores in predicting inpatient mortality by sex.

Aims & Methods

This retrospective study included 1,003 patients who underwent inpatient oesophagogastroduodenoscopy (OGD) for UGIB between January 2025 and August 2023 at a UK tertiary care centre. Glasgow-Blatchford Score (GBS), CHAMPS, ABC, Japanese score, and MAP(ASH), were calculated for each patient. Binary Logistic regression examined sex as an independent factor for 30-day inpatient mortality, with UGIB aetiology also accounted for (variceal vs non-variceal). Receiver operating characteristic (ROC) curves were used to assess each score's performance in predicting inpatient mortality separately for male and female subgroups.

Results

Out of the 1,003 admissions, 59.2% and 40.8% were males and females, respectively, with crude analysis demonstrating female mortality being slightly higher (10.5%) compared to male (8.6%). However, this was found not to be significant (p: 0.304, OR 1.251, CI: 0.816-1.917). These findings were consistent regardless of UGIB aetiology (variceal vs non-variceal).
For the 30-day inpatient mortality outcome, the ABC score demonstrated strong discriminative performance in both males (AUC: 0.804) and females (AUC: 0.835). CHAMPS and MAP(ASH) also performed consistently, with CHAMPS yielding AUCs of 0.788 in males and 0.793 in females, and MAP(ASH) showing 0.767 and 0.781 in males and females respectively. GBS performed slightly better in females (AUC: 0.743) compared to males (AUC: 0.691). The Japanese score showed poor discrimination in both sexes, particularly in females (AUC: 0.577). Overall, ABC, CHAMPS, and MAP(ASH) performed reliably across sexes.

Conclusion

Whilst crude mortality rates were higher in females than males, gender did not show to be an independent predictor of inpatient mortality, which could, however, necessitate a larger cohort size to ascertain validity. Risk scores, particularly the ABC score, maintained high and consistent predictive accuracy for inpatient mortality in both male and female patients with UGIB. These findings support the use of these tools across genders and suggest minimal gender-related performance bias in risk stratification.

Introduction

Primary biliary cholangitis (PBC) is a chronic autoimmune liver disease characterized by progressive bile duct damage and cholestasis. While ursodeoxycholic acid (UDCA) is the first-line therapy, about 40% of patients have incomplete responses, necessitating alternative treatments.

Aims & Methods

This meta-analysis evaluates the efficacy and safety of novel oral anti-cholestatic agents for PBC, focusing on key biochemical and symptomatic outcomes. A systematic literature search was conducted across electronic databases. Eligible studies included randomized controlled, retrospective, and open-label trials investigating novel oral anti-cholestatic agents in PBC patients. Data on efficacy (e.g., alkaline phosphatase [ALP] reduction) and safety outcomes were extracted and analyzed using meta-analytic techniques.

Results

Ten studies involving 878 patients were analyzed. Investigated therapies included seladelpar, fenofibrate, saroglitazar, bezafibrate, elafibranor, and budesonide. Novel anti-cholestatic agents significantly lowered ALP levels compared to controls (SMD -2.80; 95% CI [-3.56, -2.03]; p<0.00001), with saroglitazar showing the largest effect size (SMD -4.62; 95% CI [-5.54, -3.70]). Subgroup analysis revealed that fibrates (fenofibrate, bezafibrate, and saroglitazar) demonstrated the most consistent ALP reduction across studies (SMD -3.15; 95% CI [-3.89, -2.41]; p<0.00001).
In addition to ALP reduction, several agents showed improvements in other liver function tests. Bilirubin levels decreased significantly with novel therapies (MD -0.22 mg/dL; 95% CI [-0.35, -0.09]; p=0.001). Gamma-glutamyl transferase (GGT) also showed substantial reduction (SMD -1.98; 95% CI [-2.56, -1.40]; p<0.00001).
Symptomatic improvements were observed, particularly for pruritus. Bezafibrate and seladelpar demonstrated the most promising results, with mean reductions in visual analog scale scores for pruritus of 30% and 35%, respectively. Fatigue scores also improved, though to a lesser extent (SMD -0.42; 95% CI [-0.68, -0.16]; p=0.002).
Safety profiles were comparable to controls, with no significant increase in serious adverse events (OR 1.21; 95% CI [0.81, 1.83]; p=0.35). The most common adverse events were mild gastrointestinal symptoms (10-15% of patients) and transient elevations in creatinine (5-8% of patients). No significant hepatotoxicity was observed across the studies.

Conclusion

Novel oral anti-cholestatic agents show promise in managing PBC patients with suboptimal UDCA responses, demonstrating significant improvements in biochemical markers and some symptomatic relief. However, study heterogeneity, small sample sizes, and limited follow-up durations restrict direct comparisons and generalizability. Further research is needed to confirm long-term efficacy and safety.

References

1 Trivella J, John BV, Levy C. Primary biliary cholangitis: Epidemiology, prognosis, and treatment. Hepatol Commun 2023; 7: e0179. [PMID: 37267215 DOI: 10.1097/HC9.0000000000000179]
2 Purohit T, Cappell MS. Primary biliary cirrhosis: Pathophysiology, clinical presentation and therapy. World J Hepatol 2015; 7: 926-941. [PMID: 25954476 DOI: 10.4254/wjh.v7.i7.926]
3 Tanaka A, Takikawa H, Mochida S, Koike K, Miwa H, Shimosegawa T. Changing nomenclature for PBC from ‘primary biliary cirrhosis’ to ‘primary biliary cholangitis’. J Gastroenterol 2016; 51: 748-749. [PMID: 27230619 DOI: 10.1007/s00535-016-1223-z]