Introduction

Diagnosis of abdominal tuberculosis relies on microbiological tests to detect Mycobacterium tuberculosis (MTB) and histopathology. Newer microbiological tests like MGIT (culture test for MTB) and Xpert MTB Rif assay (PCR test for MTB) have an established role in diagnosing pulmonary tuberculosis (TB). This study aimed at assessing the diagnostic accuracy of these tests in abdominal tuberculosis (ATB).

Aims & Methods

We aimed to study the utility of MGIT culture and gene Xpert MTB Rif assay in diagnosing Abdominal Tuberculosis (ATB).
We conducted a retrospective study among patients diagnosed with Abdominal Tuberculosis (ATB) in 2018. The clinical and investigation details were recorded on a data sheet. This included the nature and duration of symptoms and the site of the lesion. The sample of extra-intestinal lesions was acquired under radiological guidance and sent for histopathology, MGIT culture, and Xpert test. The intestinal lesions were detected on colonoscopy or enteroscopy, and the sample was sent for histopathology and microbiological tests - MGIT & Xpert. The final diagnosis of ATB was done using composite reference standard based on the presence of histopathology findings or positive culture or the presence of diagnosed extra-intestinal tuberculosis or response to anti-tuberculosis treatment (ATT). Diagnostic yield of MGIT and Xpert tests were calculated.

Results

A total of 68 patients were studied. Forty patients had intestinal tuberculosis (ITB) and 28 patients had extra-intestinal Abdominal tuberculosis (EIATB).
In patients with ITB, mean age was 37.1±13.4 years, and 30 (70%) were males. The median duration of symptoms was four months (IQR, 2-11.3 months). Abdominal pain (80%) was the commonest symptom. Fever was noted in 37.5% of cases and diarrhea in 17.5%. MGIT culture was positive in 5(12.5%) cases. Xpert test was positive in two of the five cases with positive MGIT culture report. Another patient had Xpert positive, but MGIT culture was negative. The sensitivity of MGIT culture was 12.5%, and Xpert was 7.5%. The combined sensitivity of the two tests was 15%.
In patients with EIATB, mean age was 47.8±13.6 years and 16(57.1%) were males. Fever was present in 60.7% of cases, and abdominal pain was present in 35.7% of cases. Tissue sample for diagnosis of TB was obtained from omentum in 16(57.1%) intra-abdominal lymph node in 7(25%) and other sites in 5(17.9%) patients. Histopathology supported a diagnosis of TB in 67.9% of cases. Xpert test was positive in eight (28.6%) cases. MGIT culture was positive in 3(10.7%), of which two also had a positive Xpert test. The combined sensitivity of the two tests was 32.1%. Six of the seven intra-abdominal lymph node tissue had a positive Xpert test, while none of the omental tissue samples showed a positive result for this test.
Overall, XPERT was positive in 13 cases with a sensitivity of 19.1%. MGIT was positive in 8 cases with a sensitivity of 11.7%. The combined sensitivity of both tests was 28.6%.

Conclusion

Newer microbiological tests (MGIT, Xpert) help in the diagnosis of about one-sixth of cases with ITB and in about one-third of cases of EIATB. The faster availability of results compared to conventional culture is the key advantage, but due to the paucibacillary nature of ATB, its yield is quite low.

Introduction

The introduction of lumen-apposing metal stents (LAMSs) has revolutionized the field of therapeutic endoscopic ultrasound (EUS). In the last decade, its utilization for off-label indications has markedly increased, particularly among patients with surgically altered anatomy to establish access in the excluded segment of the gastrointestinal tract. Indications for anastomosis creation include EUS-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE), EUS-directed transgastric intervention (EDGI), or endoscopic reversal of Roux-en-Y gastric bypass (RYGB) for specific indications (see below).

Aims & Methods

This study aims to evaluate the effectiveness and safety of LAMS in patients with surgically altered anatomy for EDGE, EDGI, and reversal of RYGB. We collected data on all LAMS procedures conducted in patients with surgically altered anatomy, between October 2019 and February 2024 at the University Hospital of Ghent.
We used our prospective LAMS database and retrieved missing data from retrospective analysis of the medical patient records. The main outcome data of interest were technical success, clinical success, and adverse events. Technical success was defined as a successful placement of LAMS in the desired position. Clinical success was defined as either successful endoscopic access to the intended excluded gastrointestinal segment or achievement of the intended therapeutic goal when RYGB reversal was necessary. Adverse events were classified according to the AGREE criteria.

Results

A total of 73 LAMS procedures were performed: 70 cases of EUS-guided gastro-gastrostomy in patients with RYGB and 3 cases of EUS-guided gastro-enterostomy in patients with hepaticojejunostomy. Indications for LAMS procedures included 55 (75.3%) cases of EDGE, 13 (17.8%) cases of EDGI (such as gastroduodenoscopy and EUS), and 5 (6.8%) cases of RYGB reversal. Reversal of RYGB was required for one cachectic patient due to metastatic cholangiocarcinoma, three patients with hyperinsulinemic hypoglycemia, and one patient with therapy-resistant small intestinal bacterial overgrowth (SIBO).
The overall technical and clinical success rates were very high at 97.3% and 95.9%, respectively. Adverse events were observed in 11 out of 73 (15.1%) cases, including 7 (9.6%) minor events (AGREE score < 3) and 4 (5.5%) major events (AGREE score ≥ 3). Major events included stent migration (N=1), persistent fistula (N=2), and respiratory desaturation (N=1). All events could be successfully managed, and there were no procedure-related deaths. In 69.9% of cases, our method involved a dual-step approach, strategically implemented to await fistula maturation and reduce the risk of perforation. The median LAMS dwell time was 38 days (range 7, 431). LAMS was removed in 72.6% of the cases. Loss of LAMS patency occurred in 1 out of 73 (1.4%) cases and was endoscopically managed.

Conclusion

In conclusion, our study demonstrates that EUS-GG and EUS-GE offer an effective and safe approach to create anastomoses between gastrointestinal (GI) segments when performed by experts. With high technical (97.3%) and clinical (95.9%) success rates, LAMS proves beneficial for accessing excluded GI segments and reversing RYGB. Adverse events (15.1%) were mostly minor and manageable, with no procedure-related mortality. The extended patency duration and low re-intervention rate highlight LAMS as a minimally invasive and durable option in therapeutic endoscopic ultrasound procedures. Further prospective studies are required.

Introduction

Colonoscopy is the ‘gold standard’ investigation for assessment of the large bowel allowing diagnosis, biopsies, and therapy to be undertaken. Colonoscopy detects and prevents colorectal cancer through detection and removal of polyps, and is important in the diagnosis and treatment of non-neoplastic conditions. Poor quality colonoscopy is associated with increased rates of interval cancers. High quality colonoscopy cannot occur without good quality bowel preparation. Evidence in the UK show that 22% of failed colonoscopies were due to poor bowel preparation. Apart from the bowel cleansing agent, dietary restriction prior to colonoscopy has been shown to enhance quality of bowel preparation at colonoscopy.

Aims & Methods

We aimed to assess the information received and followed by patients in terms of dietary modification prior to colonoscopy.
A single centre prospective analysis of 60 consecutive patients attending colonoscopy at Chase Farm Hospital in London was undertaken in May 2022. Patients were asked to complete a questionnaire with information gathered about: type of bowel prep undertaken, whether written information about how to take bowel prep was received, whether a telephone consultation explaining dietary restriction prior to procedure happened, whether they followed a low fibre diet and the amount of fluid drunk.

Results

57 patients returned the questionnaire.
Of the 57 patients, 39% patients received written information on dietary restriction. A further 35% of patients received telephone information, 26% of patients receiving both written and verbal information. 56.9% of patients followed the 3 day dietary restriction. The quality of bowel preparation was inadequate (fair and poor by Aronchick scale) in 60% of those who did not follow the low fibre diet compared to 24% when followed. Patients who had seen a clinician in clinic and patients undergoing surveillance procedure were more likely to follow dietary restriction compare to direct access patients.

Conclusion

In this prospective study of clinical practice, we conclude that advice regarding dietary fibre restriction prior to colonoscopy is variable. In clinical practice, there is low compliance of dietary restriction prior to colonoscopy. We find that those who followed a low fibre diet are 40 % more likely to have a favourable bowel preparation compared to those following a high fibre diet. Those that had inadequate bowel prep required a repeat colonoscopy adding to the burden of the already stretched service. We recommend improvements in the implementation of the low residue diet in addition to the guidance of cleansing agents prior to colonoscopy.

Clinical Case Summary

Male, 72 years old, past medical history of diabetes mellitus and diabetic gastroparesis with only partial improvement after medical treatment with prokinetics, antiemetics and oral antidiabetic drugs.
Due to gastric adenocarcinoma, he underwent curative submucosal dissection(ESD) 2 years before and developed pyloric stenosis 1 month after ESD, refractory to endoscopic dilation and not amenable to placement of a biodegradable stent due to stomach morphology.
The patient was admitted to the to the Emergency Department after 2 weeks of postprandial vomiting, weight loss(12%/1 month) and 2 days of disorientation. On examination, he was partially oriented, hemodynamically stable, with mucocutaneous dehydration.
He was hospitalized, started on prokinetics and a nasogastric tube was placed for drainage. Analysis results on admission were normal except for a cystitis and empirical antibiotic was initiated.
During hospitalization, he suffered acute depression of consciousness with stupor and bilateral ophthalmoplegia, followed by delirium.
CT angiography excluded acute vascular events and cerebrospinal fluid(CSF) cytochemical analysis was normal.
Due to clinical suspicion of Wernicke's encephalopathy, he was started on intravenous thiamine at therapeutic dose, anticonvulsant, antibiotic at meningeal dose and antiviral, while waiting for microbiological results.
MRI revealed hypersignal in T2 and FLAIR with restriction in the diffusion study in the midbrain and the thalamus - findings suggestive of Wernicke's Encephalopathy. The remaining study, including EEG and complete CSF analysis excluded other etiologies.
There was a progressive improvement of aphasia, apraxia, ataxia and nystagmus. After motor rehabilitation and vitamin supplementation, 6 months later, he maintains a short-term memory deficit (Korsakoff Syndrome).
Wernicke's Encephalopathy due to gastroparesis is a rare occurrence in the literature with potentially irreversible sequelae, as illustrated.

References

Introduction

Patients with ulcerative colitis (UC) report that UC negatively affects their quality of life (QoL), including sexual functioning, satisfaction, and drive.^1,2 These effects are rarely discussed with or by gastroenterologists in clinical practice. The CONFIDE study aims to elucidate the impact of symptoms on the lives of patients with moderate to severe UC in the United States (US), Europe (EU5; France, Germany, Italy, Spain, and UK), and Japan. Data presented here are from the US and EU5.

Aims & Methods

Online, quantitative, cross-sectional surveys were conducted (July–September 2021). Criteria based on previous treatment, steroid use, and/or hospitalization were used to define moderate-to-severe UC. Data collected included patient perspectives on the impact of UC on sexual activity. Sexual activity was not limited to intercourse and included activities such as masturbation.

Results

Surveys were completed by 200 US patients (male [M]=62%, mean age 40 years) and 556 EU5 patients (M=57%, mean age 39 years). Of these, 77% US and 54% EU5 patients were receiving advanced therapy (biologic/novel oral) and 52% and 73% were receiving steroids at the time of survey completion, respectively. Overall, 63% US patients (M=55%, female [F]=77%) and 53% EU5 patients (M=47%, F=60%) reported avoiding or decreasing sexual activity due to UC in the 3 months prior to the survey. Among these patients (US: N=126; EU5: N=292), most frequently reported reasons for avoidance of sexual activity were bowel urgency (BU; 41%), decreased sexual desire (37%), and fear of BU-related accidents (34%) in the US and fear of faecal seepage (37%), fear of BU-related accidents (36%), and BU itself (31%) in EU5. Although reasons for avoiding sexual activity were broadly similar between sexes, higher percentage of male patients from both US and EU5 (US: M=33%, F=24%; EU5: M=42%, F=33%) reported fear of faecal seepage as a factor affecting sexual activity. Conversely, higher percentages of female patients reported perianal pain (M=13%, F=19%) and self-consciousness (M=13%, F=24%) as reasons for avoiding sexual activity in the US and decreased sexual desire (M=16%, F=26%), BU (M=26%, F=36%) and fatigue (M=14%, F=22%) in EU5.

Conclusion

In both US and EU5 populations, >50% patients with moderate-to-severe UC reported avoiding or decreasing sexual activity due to UC, with bowel urgency and bowel urgency-related accidents being among the top three reasons. In addition to other QoL parameters, impact of UC on patients’ sexual health needs to be assessed in routine clinical practice.

References

¹Bulut AE, et al. Turk J Gastroenterol. 2019;30:33-39.
²Jedel S, et al. Inflamm Bowel Dis. 2015;21:923-38.

Disclosure

Simon Travis, Grants: Ferring Pharmaceuticals, AbbVie, Schering-Plough, MSD, Procter & Gamble, Warner Chilcott, International Organization for the Study of IBD, ECCO, UCB, Vifor Pharma, Normal Collision Foundation, Buhlmann, Takeda, Janssen, Pfizer, and Eli Lilly and Company.
Marla C. Dubinsky, Consultancy fees: AbbVie, Arena Pharmaceuticals, Boehringer Ingelheim International GmbH, Bristol Myers Squibb, Celgene Corporation, Eli Lilly and Company, F. Hoffman-La Roche Ltd, Genentech Inc., Gilead Sciences, Janssen, LLC, Pfizer, Prometheus Biosciences, Takeda Pharmaceuticals USA, Inc., and UCB; Stockholder: Trellus Health Inc.; Research support: AbbVie, Janssen, LLC, Pfizer, and Prometheus Biosciences.
Toshifumi Hibi, Consultancy fees/grant/research support/speaker: AbbVie GK, ActivAid, Alfresa Pharma Corporation, Apo Plus Station, Aspen Japan K.K, Bristol-Myers Squibb, Celltrion, EA Pharma, Eli Lilly and Company, Ferring Pharmaceuticals, Gilead Sciences, Janssen, JIMRO, JMDC Inc., Kyorin, Mitsubishi-Tanabe Pharma Corporation, Mochida Pharmaceutical, Nichi-Iko Pharmaceutical, Nippon Kayaku Co. Pfizer, Takeda Pharmaceutical, Zeria Pharmaceutical, and MIYARISAN Pharmaceutical.
David T. Rubin, Grants/contracts: Takeda; Consultancy fees: AbbVie, Altrubio Inc., Allergan, Inc., American College of Gastroenterology, Arena Pharmaceuticals, Athos Therapeutics, Bellatrix Pharmaceuticals, Boehringer Ingelheim International GmbH, Bristol Myers Squibb, Celgene Corp/Syneos, Cornerstones Health, Inc. (non-profit), GalenPharma/Atlantica, Genentech/Roche, Gilead Sciences, GODURN, LLC, InDex Pharmaceuticals, Ironwood Pharmaceuticals, Iterative Scopes, Janssen, Eli Lilly and Company, Materia Prima, Pfizer, Prometheus Biosciences, Reistone Biopharma, Takeda, and Techlab Inc; Stockholder: Altrubio and Datos Health.
Remo Panaccione, Consultancy/speaker fees and/or advisory board member: AbbVie, Amgen, Arena Pharmaceuticals, Bristol-Myers Squibb, Celgene, Eli Lilly and Company, Ferring, Fresenius Kabi, Gilead Sciences, Janssen, Merck, Organon, Pfizer, Roche, Sandoz, Shire, and Takeda; Consultancy fees and/or advisory board member: Alimentiv, AstraZeneca, Biogen, Boehringer Ingelheim, Genentech, Glaxo-Smith Kline, JAMP Bio, Mylan, Novartis, Oppilan Pharma, Pandion Pharma, Progenity, Protagonist Therapeutics, Sublimity Therapeutics; Consultancy fees: Abbott, Celltrion, Cosmos Pharmaceuticals, Eisai, Elan, Galapagos, JAMP Bio, Pendopharm, Satisfai Health, Theravance Biopharma, Trellus, Viatris, and UCB.
Stefan Schreiber, Consultancy and lecture fees: AbbVie, Amgen, Arena Pharmaceuticals, Bristol Myers Squibb, Celltrion, Falk, Ferring Pharmaceuticals, Galapagos/Gilead, Genentech/Roche, Eli Lilly and Company, Janssen, MSD, Pfizer, and Takeda.
Christian Atkinson, Employee: Adelphi Real World; Consultancy: Eli Lilly and Company in connection with this study.
Alison P. Bleakman, Cem Kayhan, Theresa H. Gibble, Christophe Sapin, and Eoin J. Flynn are employees and stockholders of Eli Lilly and Company.

Introduction

Gastroenterology (GE) is a medical discipline that studies all diseases of the digestive system. It comprises several areas of study and offers a large variety of sub-specializations: proctology, interventional endoscopy or even digestive oncology. The decisive elements in the choice of this specialty vary among interns. The aim of our study is to determine the various factors influencing the choice of gastroenterology as a specialty among medical interns.

Aims & Methods

This is a cross-sectional, multicentric, survey-type study, conducted from September 1 to 30, 2023, involving 7 national medical faculties. All medical interns, regardless of sex or age, participated in our study.
An electronic survey with 29 items was created using Google Forms®. It was divided into two parts: the first part contained 13 questions on socio-demographic characteristics and exposure to GE during the academic curriculum, while the second part concerned the factors motivating the choice or not of GE as a specialty.
A statistical analysis using the Fisher’s exact test was performed. P values of <0.05 were considered statistically significant. Data were analyzed using Jamovi (Version 2.3).

Results

A total of 329 responses were collected: the majority were women 208 (63.2) with a F/M sex ratio of 1.7 and a median age of 27 [25; 28] years. The majority had already completed a GE rotation during their training course n=205 (62.3), of which 90 (44.1) had found it "satisfactory". More than half of the participants n= 178 (54.1) had already considered GE as a future specialty, and this choice was mostly made during GE lectures given in medical school n= 66 (36.9). Among those who had never considered GE, the main reasons were lack of interest in the specialty, the fact that it is a medical specialty, lack of information about GE, potential remuneration, and dissatisfaction with GE rotation during the training course (59.2%, 28.9%, 13.9%, 10.4% and 10% respectively).
Among those who finally opted for GE, the majority were women (70.2% vs. 29.8%, p=0.004). Satisfaction with the GE rotation during the training course had an impact on the final choice: "satisfactory" vs. "mediocre" (43.8% vs. 6.3% p=0.009).
Multivariate analysis showed that early interest in fields such as endoscopy (OR= 4.46, CI95%: 1.44-13.78, p=0.009) or proctology (OR= 4.26, CI95%: 1.01-18.01, p=0.05) increased the chance of choosing GE.

Conclusion

This study showed that there is a gender disparity in the choice of GE as a specialty. The fact that it is a medical discipline may lead men to choose another path. Our study also highlighted the importance of GE training courses during the medical curriculum to motivate interns to join our specialty, as well as the need to spotlight certain areas such as endoscopy or proctology.