Introduction

The use of contrast-enhanced endoscopic ultrasound (CE-EUS) for characterizing solid pancreatic masses has improved diagnostic capabilities. We aimed to evaluate the performance of an artificial intelligence (AI)-powered system for differential diagnosis of pancreatic adenocarcinoma using CE-EUS.

Aims & Methods

The methodology integrates advanced imaging analysis and machine learning (ML) to develop an automated framework for pancreatic tumor characterization using EUS. A convolutional neural network (CNN) is first trained on labeled non-contrast EUS images to detect and segment the pancreas and tumor regions accurately. Once trained, the CNN is applied to new cases, identifying regions of interest (ROIs) in the non-contrast images, which are subsequently mapped onto the corresponding contrast-enhanced images for further analysis. Time-Intensity Curve (TIC) analysis was performed on the mapped ROIs, extracting a comprehensive set of quantitative parameters describing contrast enhancement dynamics. These parameters include temporal metrics (e.g., time to peak, rise time), intensity measures (e.g., peak intensity, wash-in intensity), slopes (e.g., wash-in and wash-out rates), area-based metrics (e.g., area under the curve), and perfusion-related characteristics (e.g., perfusion index, blood flow). The extracted TIC parameters are then used to train a feedforward neural network (FNN), which learns to differentiate diagnostic categories based on the perfusion characteristics of the lesions. In the final integrated model, the CNN detects pancreas and tumor regions, maps them to contrast-enhanced images, computes TIC parameters, and feeds these into the FNN to provide automated diagnostic predictions.

Results

Retrospective analysis was performed on a prospectively collected dataset of 120 CE-EUS videos obtained from patients with solid pancreatic masses in 3 tertiary referral centers. The dataset included 88 pancreatic adenocarcinomas, 1 lymphoma, 4 metastatic lesions, 10 neuroendocrine neoplasms (G1/G2), 15 cases of chronic pancreatitis, and 2 solid pseudopapillary neoplasms (SPNs). Diagnostic performance was evaluated by calculating sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy. Based on CNN analysis, both precision and recall were also calculated. The AI-powered CE-EUS system achieved high diagnostic performance, with an accuracy of over 95% for the diagnosis of pancreatic adenocarcinoma. Precision and recall were also excellent for differentiating adenocarcinoma from other pancreatic lesions based on CNN analysis.

Conclusion

This novel AI-based approach using CE-EUS reliably distinguished pancreatic adenocarcinoma from other solid pancreatic masses. Real-time analysis of time-intensity curve parameters enhances diagnostic accuracy and offers a promising adjunct to traditional EUS methods. Further prospective validation is warranted to confirm these findings and explore clinical applicability.

References

1. Săftoiu A, Vilmann P, Bhutani MS, Hassan H, Hawes R, Dietrich CF, et al. Enhanced endoscopic ultrasound imaging for pancreatic lesions: A review.
World J Gastrointest Endosc. 2022 Jul 16;14(7):369–84. doi:10.4253/wjge.v14.i7.369 PMID: 35967758; PMCID: PMC9367228.
2. Liang T, Zhang H, Wang Y, Sun Y, Ma K, Liu W, et al. Artificial intelligence-assisted endoscopic ultrasound for detection of pancreatic lesions: A systematic review and meta-analysis. World J Gastroenterol. 2023 Feb 21;29(7):1150–1164. doi:10.3748/wjg.v29.i7.1150 PMID: 36849883; PMCID: PMC10720860.

Introduction

Alcohol-induced acute pancreatitis (AP) is a common form of AP, while alcoholic hepatitis (AH) is a severe complication of alcoholic liver disease. Maléth et al. demonstrated that ethanol and fatty acids reduce cystic fibrosis transmembrane conductance regulator (CFTR) expression and activity, worsening alcohol-induced AP. Previously, we showed that ethanol and fatty acids disturb the CFTR-PMCA interaction, leading to disruped intracellular Ca²⁺ balance, exacerbating pancreatitis and potentially hepatitis. Previously Berrocal et al. described that MB reverses the inhibitory effect of Tau on PMCA, suggesting that its beneficial effect is based on the preservation of endogenous Ca²⁺-ATPase activity. Methylene blue (MB) is known for its antioxidant and mitochondrial protective properties, which can also influence intracellular Ca²⁺ regulation. Here we hypothesize that potentiating PMCA with methylene blue could have a protective effect in alcohol-induced AP and AH.

Aims & Methods

This study investigates MB’s effect on alcohol-induced AP severity and its underlying protective mechanisms in alcohol-related diseases. The effects of MB were assessed in mouse pancreatic (MPO), mouse liver (MLO), and human pancreatic ductal organoid (HPO) cultures. Microfluorimetric measurements were performed using an inverted fluorescence microscope. The polarized expression of ion channels was analyzed via immunofluorescence (IF). Gene expression changes were examined using qPCR, while mitochondrial membrane potential was assessed with TMRM and JC-10 staining. Cytotoxicity was evaluated using the CellTiter-Glo® 3D assay. Alcohol-induced AP and AH were modeled in wild-type FVB/N mice. AP was induced by repeated ethanol (EtOH) and palmitoleic acid (POA) injections, while AH was provoked using a 5% ethanol-fed Lieber-DeCarli diet.

Results

Fluorescent Ca²⁺ measurements showed that MB significantly potentiated PMCA activity following EtOH and PA exposure in MPOs, MLOs, and HPOs compared to EtOH-PA-treated groups. Mitochondrial membrane potential measurements confirmed MB’s protective effect. Gene expression analysis revealed no significant differences in CFTR, PMCA4, or ORAI1 expression between EtOH-PA and MB-treated groups. IF staining of PMCA4 demonstrated a defined apical localization in EtOH-PA + MB-treated groups. In experimental AH, MB’s effects were evaluated using Oil Red O and Trichrome staining, along with serum ALAT, ASAT, and triglyceride (TG) levels. In alcohol-induced AP, MB treatment significantly reduced serum amylase levels, oedema, leukocyte infiltration, and necrosis scores compared to the EtOH-POA group.

Conclusion

MB treatment mitigates the harmful effects of EtOH and PA exposure by enhancing PMCA activity, preserving mitochondrial function, and promoting PMCA4’s apical localization. Although no significant changes were observed in CFTR, PMCA4, or ORAI1 gene expression, histological and biochemical analyses highlight MB’s potential in alleviating alcohol-induced AP, as evidenced by reduced oedema, leukocyte infiltration, necrosis scores, and serum amylase levels. These findings suggest MB as a promising therapeutic candidate for protecting cellular and mitochondrial integrity in alcohol-related diseases.

Disclosure

I declare no conflict of interest

Introduction

Pancreatic fistulas (PFs) represent a remarkable clinical challenge after abdominal surgery, pancreatitis, or abdominal trauma, with significant morbidity and non-negligeable mortality. Pancreatic endoscopy plays a pivotal role in the setting of recent trend toward aggressive yet minimally invasive surgery-sparing PFs management. Mutignani et al. recently proposed a morpho-functional pancreatographic classification of PFs aimed at targeting the best suited endoscopic treatment option for each PF type.

Aims & Methods

The primary aim of this study is to evaluate efficacy and safety of endoscopic PFs treatment, according to the Mutignani et al. classification; the secondary aim is the identification of independent variables significantly associated with different treatment clinical success rate.
Monocentric data prospectively collected between March 2011 and July 2024 on patients referred to the Interventional Endoscopic Unit of ASST Grande Ospedale Metropolitano Niguarda who underwent endoscopic treatment of a PF was retrospectively analysed.

Results

A total of 110 patients were included (M 75.5%, median age 61 years [IQR 46-72]). 75/110 (68.2%) were post-surgical (33 after pancreaticoduodectomy, 23 distal pancreatectomy, and 19 other abdominal surgery), 27/110 (24.5%) developed after pancreatitis, and 8/110 (7.3%) were post-traumatic. 17/110 (15.5%) were type I PF [9 (53%) T, 5 (29.4%) H, 3 (17.6%) B], 38 (34.5%) type II [27 (71.1%) O, 11 (28.9%) C], and 55 (50%) type III [35 (63.6%) D, 20 (36.4%) P]. Median treatment delay was 9 days [IQR 5-22]. ERCP was first endoscopic approach in 92 cases (83.6% - of which 6.5% after rendez-vous), EUS-guided in 14 (12.7%), and combined in 4 (3.6%). Mutignani et al classification adherence was 98.2%. Technical success rate was 100% (91.8% at first approach), clinical success rate was 97/105 (92.4%). Early AEs occurred in 15 cases (14.3% - 33.3% of them infections), late AEs occurred in 8 (7.6% - 100% new pancreatic strictures). 9/105 (8.6%) patients died due to fistula-related causes during follow-up, PF recurrence occurred in 2 cases (2.1%). At univariate analysis, older age, presence of heart diseases, presence of sepsis at clinical presentation, class C ISGPF fistula, and high-volume PF proved to be significantly more frequent among patients without clinical success compared to those with clinical success (median 72.5 [IQR 54.3-82.7] VS 59 [IQR 46-70.1], p=0.0312; 37.5% VS 2.3%, p=0.0038; 87.5% VS 39.8%, p=0.0199; 57.1% VS 14.3%, p=0.0182; 87.5% VS 42.7%, p=0.0230, respectively). At multivariate analysis, only the presence of heart diseases confirmed to be significantly associated to the absence of clinical success (OR 2.65, 95%CI: 1.5-3.8, p=0.0217).

Conclusion

High adherence to the Mutignani et al classification system for PFs endoscopic treatment proved to high clinical success and low rate of AEs. Targeted management of PF is not only feasible but also highly effective, basically regardless of patient’s and PF’s baseline characteristics. Further large-scale prospective multicentric studies are warranted to confirm these findings and refine the optimal treatment strategies.

References

M. Mutignani et al., “Pancreatic Leaks and Fistulae: An Endoscopy-Oriented Classification,” Dig Dis Sci, vol. 62, no. 10, pp. 2648–2657, Oct. 2017, doi: 10.1007/S10620-017-4697-5.
C. Bassi et al., “The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 Years After,” Surgery, vol. 161, no. 3, pp. 584–591, Mar. 2017, doi: 10.1016/J.SURG.2016.11.014.
G. Malleo, A. Pulvirenti, G. Marchegiani, G. Butturini, R. Salvia, and C. Bassi, “Diagnosis and management of postoperative pancreatic fistula,” Langenbecks Arch Surg, vol. 399, no. 7, pp. 801–810, Oct. 2014, doi: 10.1007/S00423-014-1242-2.

Disclosure

Authors have nothing to declare.

Introduction

Autoimmune pancreatitis (AIP) is a rare, immune-mediated form of chronic pancreatitis, classified into three subtypes. Type 1 AIP, the pancreatic manifestation of IgG4-related disease, often presents with multisystem involvement and frequent relapse (1,2). Type 2 AIP is pancreas-limited, tends to affect younger individuals, and is commonly associated with inflammatory bowel disease (IBD) (2,3). A third form—checkpoint inhibitor-related pancreatitis (CIP or Type 3 AIP)—has been recently described in patients receiving immune checkpoint inhibitors, typically asymptomatic but may result in pancreatic atrophy (4).
Precise subtyping is critical due to differences in clinical behavior, relapse risk, and treatment response (1,2,3). We present a single-center series comparing clinical, radiologic, and histopathologic characteristics of Type 1 and Type 2 AIP.

Aims & Methods

We retrospectively reviewed 20 patients diagnosed with AIP between 2020–2024 at a tertiary center. Classification followed International Consensus Diagnostic Criteria (1). Diagnostic evaluation included endoscopic ultrasound (EUS), serum IgG4 levels, and contrast-enhanced CT/MRI/MRCP (1,2). EUS-guided fine-needle biopsy (FNB) was performed where malignancy could not be excluded. Histopathology differentiated lymphoplasmacytic sclerosing pancreatitis (LPSP, Type 1) from idiopathic duct-centric pancreatitis (IDCP, Type 2) (2). Data on extra-pancreatic involvement, steroid response, and relapse were collected.

Results

Fifteen patients were diagnosed with Type 1 AIP and five with Type 2. Type 1 patients had a mean age of 63 years and were predominantly male (80%). Obstructive jaundice was the most common presentation. All had elevated serum IgG4. EUS revealed diffusely hyperechoic parenchyma and long-segment ductal narrowing. Histology confirmed LPSP. Extra-pancreatic involvement was observed in 60%, most commonly IgG4 cholangitis. All responded to corticosteroids; 40% relapsed within one year and received rituximab (5).
Type 2 patients had a mean age of 38, with equal gender distribution. Presenting symptoms included abdominal pain and acute pancreatitis. Serum IgG4 was normal in all cases. EUS revealed focal hypoechoic lesions with short-segment narrowing. Histology confirmed IDCP. Two patients (40%) had ulcerative colitis. All achieved remission with steroids, and no relapses were observed (2,3).

Conclusion

This series emphasizes the distinct clinical courses of AIP subtypes. Type 1 AIP represents a systemic IgG4-related disease with high relapse risk, often requiring long-term immunosuppression (5). Type 2 AIP affects younger patients, remains confined to the pancreas, and shows sustained remission after steroid therapy (2,3). Accurate classification using EUS, MRCP, IgG4, and histology is crucial for appropriate management and long-term outcomes (1,2).

References

1. Hart PA, Zen Y, Chari ST. Recent Advances in Autoimmune Pancreatitis. Gastroenterology. 2015;149(1):39–51.

2. de Pretis N, Crinò SF, Amodio A, et al. Type 2 autoimmune pancreatitis: Clinical features and long-term follow-up in an Italian cohort. United European Gastroenterol J. 2024;12(1):50–59.
   

3. Lohr JM, Dominguez-Munoz E, Rosendahl J, et al. United European Gastroenterology evidence-based guidelines for the diagnosis and therapy of chronic pancreatitis (HaPanEU). United European Gastroenterol J.2017;5(2):153–199.

4. Lamarca A, Dhani N, Hubner RA, et al. Immune checkpoint inhibitor-induced autoimmune pancreatitis (Type 3 AIP): Emerging entity with distinct features. Ann Oncol. 2023;34(3):385–393.
   

5. Ghazale A, Chari ST, Zhang L, et al. Treatment of relapsing autoimmune pancreatitis with immunomodulators and rituximab: The Mayo Clinic experience. Clin Gastroenterol Hepatol. 2012;10(6):640–646.

Introduction

Gene therapy holds great promise for the treatment of various diseases. AAVpan mediated SPINK1 overexpression has shown considerable promise in alleviating pancreatitis ^[1]. However, in the case of severe pancreatitis induced by high-dose caerulein administration, the protective effect was not markedly evident possibly due to the insufficient expression of SPINK1. To ensure therapeutic levels of hSPINK1 expression within the safe dosage range of AAV, we introduced the short intron 1 (mini intron1) sequence of hSPINK1 gene to explore whether mini-intron could enhance hSPINK1 expression, and validated the therapeutic efficacy of the AAVpan-hSPINK1-mini intron1 in pancreatitis models.

Aims & Methods

The first intron of human SPINK1 (1.8 kb) conforms to significantly enhance gene expression ^[2]. Considering limited packaging capacity of AAV (4.7 kb), we introduce the first and last 50 base pairs (which do not affect splicing) into hSPINK1 cDNA to construct hSPINK1-mini intron1. First, we investigated whether mini intron could enhance hSPINK1 overexpression: the hSPINK1 expression levels in AAVpan-hSPINK1 and AAVpan-hSPINK1-mini intron1 group were compared using qRT-PCR, Western blot, and trypsin-inhibition assays. The stability of hSPINK1 mRNA in both groups were evaluated following in vitro transcriptional inhibition with actinomycin D. Then, we evaluated the safety of mini intron-mediated hSPINK1 overexpression by detecting hepatic and renal function as well as pancreatic histology. Further, we constructed cerulein-induced severe acute pancreatitis model (250 μg/kg/h) to determine the protective effectiveness of mini intron-mediated overexpression.

Results

The AAVpan-hSPINK1-mini intron1 demonstrated substantially enhanced hSPINK1 expression compared to the AAVpan-hSPINK1. Quantitative analysis revealed a remarkable 30-fold increase in hSPINK1 mRNA levels, 7-fold elevation in protein expression, and 1.5-fold improvement in trypsin-inhibition activity in the AAVpan-hSPINK1-mini intron1 group than those in AAVpan-hSPINK1 group. The addition of actinomycin D resulted in continuous decay of hSPINK1 mRNA in AAVpan-hSPINK1 group, whereas the hSPINK1 mRNA levels in AAVpan-hSPINK1-mini intron1 group remained stable, indicating that mini intron1 effectively stabilized hSPINK1 mRNA. In safety analysis, the histological analysis of liver and pancreas, hepatic and renal function, as well as serum amylase remained within normal levels in both groups for up to 8 weeks post-injection. In the AAVpan-hSPINK1 group, mice with high-dose caerulein-induced SAP exhibited typical pancreatitis phenotypes. In contrast, the AAVpan-hSPINK1-mini intron1 attenuated SAP, implying a dose-dependently protective effect of hSPINK1 overexpression.

Conclusion

The enhanced mini intron could safely enhanced hSPINK1 expression level and trypsin-inhibition activity by improving mRNA stability, representing a promising strategy for optimizing transgene expression and opening up new possibilities for the treatment of severe pancreatitis and potentially other diseases in the field of gene therapy.

References

[1] Wang YC, Mao XT, Sun C, et al. Pancreas-directed AAV8-hSPINK1 gene therapy safely and effectively protects against pancreatitis in mice [J]. Gut, 2024, 73(7): 1142-55.
[2] Kereszturi E, Király O, Sahin-Tóth M. Minigene analysis of intronic variants in common SPINK1 haplotypes associated with chronic pancreatitis [J]. Gut, 2009, 58(4):545-9.

Introduction

Massive gastrointestinal bleeding is a clinical condition that is poorly studied due to its abrupt presentation, involvement of various clinical services, and the high and rapid mortality of patients. We present the preliminary results of a multicenter registry that includes 21 hospitals from Spain and Hispanic America, analyzing factors related to mortality and need for intervention.

Aims & Methods

Since January 2023, 403 patients over 18 years old who presented to the emergency departments of participating hospitals with massive gastrointestinal bleeding, defined as bleeding accompanied by signs of shock and requiring transfusion of at least 2 units of blood within the first 24 hours of admission, were included. Demographic variables, comorbidities, treatments including NSAIDs, antiplatelets, and anticoagulants, clinical presentation variables, medical, endoscopic, and surgical variables, and a 6-month follow-up were collected.
The aim of this study was to analyze factors related to mortality and the need for intervention in patients with massive gastrointestinal bleeding.

Results

A total of 403 patients with a mean age of 64.5 ± 15.7 years were included (male 68.7%). Main comorbidities were cirrhosis (31%), diabetes (28%) and a previous UGIB (25%). 8.4% of patients had already been admitted to the hospital, and 29% were on antithrombotic (16.6% antiplatelets and 16.4% anticoagulants). On admission we observed SPB: 91±22 mmHg, heart rate 101 ± 21; and an altered mental status in 31%. Mean hemoglobin levels 7.6±2.5 g/dl, urea: 98±67, albumin 2.16±1.3, INR: 3.9±7. The most common causes were esophageal varices (29%), gastric ulcer (25%) and duodenal ulcer (25%). Endoscopic intervention was needed in 60%, with mortality rate of15.4%. Mean admission was 8.6±10 days, and patients needed 4±3 red blood cells units. When analyzing in-hospital mortality, we observed that the age of patients who died was higher than that of survivors (68.2±15 vs. 63.6±16; p=0.033), with the former requiring more packed red blood cells (5±5.5 vs. 3.5±2; p=0.043). Patients who died had a lower frequency of gastric ulcer (14% vs. 27%; p=0.034), a higher frequency of altered mental status (42.6% vs. 29%; p=0.036), and a lower rate of endoscopic therapy applied (43.3% vs. 63.6%; p<0.0001). In logistic regression, gastric ulcer etiology and endoscopic therapy were protective factors against mortality (Table 2).
Regarding the need for intervention, more patients with liver cirrhosis required it (73% vs. 60%, p=0.018), patients with hematemesis (73% vs. 52%; p<0.0001), patients without melena (60% vs. 76%; p=0.002), with syncope (76.3% vs. 61%; p=0.06), etiologies other than gastric ulcer (78% vs. 56%; p=0.028), and the presence of esophageal varices (83% vs. 57%; p<0.0001). In binary logistic regression, liver cirrhosis, hematemesis, and syncope were risk factors for the need for intervention.

Conclusion

Age, altered mental status, and lower frequency of endoscopic therapy are risk factors for mortality due to massive gastrointestinal bleeding. Gastric ulcer as an etiology and receiving endoscopic therapy acted as protective factors against mortality. Indeed, in both situations, it might be related to an opportunity window to receive appropriate treatment, especially when compared with more cataclysmic types of bleeding, such as variceal or posterior duodenal bulb wall, which sometimes can be challenging and utterly abrupt. Regarding the need for intervention, liver cirrhosis, hematemesis, and syncope were independent risk factors for the need for endoscopy, surgery, or interventional radiology.