Introduction

Upper gastrointestinal bleeding (UGIB) is the most common diagnostic and therapeutic emergency in hepato-gastroenterology, potentially life-threatening and requiring multidisciplinary management.
Anti-thrombotic (AT) drugs commonly prescribed for cardiovascular diseases are considered a recognised risk factor for UGIB. However, few studies have evaluated their effect on endoscopic outcomes in patients admitted for UGIB, and have concluded that the results remain controversial.

Aims & Methods

Aims: Evaluate the effect of AT use on endoscopic outcomes in patients admitted for UGIB.
Methods: This is a prospective monocentric cross-sectional study of 332 patients conducted between June 2020 and August 2021.We considered as users of AT drugs all patients on antiplatelet agents (low-dose aspirin, thienopyrimidines) and/or anticoagulants (vitamin K antagonists, direct-acting anticoagulants, heparin).

Results

The average age was 59+/−16.7 years. Our series was characterised by a clear male predominance of 77.1%.63 patients (19%) were taking AT drugs (41 antiplatelet, 39 anticoagulant).The two groups differed in age (68 vs 57; p<0.001), comorbidities (75.8% vs 16.7%; p<0.001), however there was no statistically significant difference in active bleeding at endoscopy (12.7%vs 16.8%; p=0.425), and the need for endoscopic haemostasis (7.9%vs 16%; p=0.1).In multivariate analysis and adjusting for age, sex, comorbidities, presence of active bleeding and use of antithrombotics, only the presence of active bleeding could predict the need for endoscopic haemostasis. Indeed, the presence of active bleeding at the time of endoscopy multiplies by 26 the risk of recourse to endoscopic haemostasis (OR: 26, CI: 12.9–62.15, p<0.001), whereas the use of AT drugs does not influence the need for endoscopic haemostasis (OR: 0.386, CI: 0.105- 1.42, p=0.154)

Conclusion

Older patients using AT admitted for UGIB do not appear to have an increased risk of active bleeding at endoscopy or needing endoscopic haemostasis.

Clinical Case Summary

Introduction: Cap polyposis is a rare benign inflammatory condition characterized by inflammatory polyps covered with a fibrinopurulent exudate. It is more commonly observed in women and the elderly, although it can present at any age. The disease typically affects the rectum and sigmoid colon. The most frequent symptoms include mucous diarrhea and rectal bleeding. It has been associated with mucosal prolapse due to altered intestinal motility, Helicobacter pylori infection, and even intestinal dysbiosis.
Endoscopy: A 46-year-old male with no relevant personal or family medical history presented with altered bowel habits, characterized by increased stool frequency, decreased consistency, and the presence of mucus and blood, along with tenesmus and urgency. H. pylori testing was negative. Colonoscopy revealed numerous sessile and pedunculated polyps with an inflammatory appearance distributed throughout the colon, predominantly in the sigmoid and rectum. Most polyps were covered at their apex by a fibrinopurulent exudate (Figures 1–4). The colonic mucosa adjacent to the polyps appeared normal. Multiple biopsies were taken, confirming inflammatory polyps. A first therapeutic colonoscopy was performed, during which multiple polyps consistent with cap polyps were resected (Figure 5). Additional sessions were scheduled to complete polyp resection. Furthermore, a molecular study was performed using next-generation sequencing (NGS) with a multigene panel including genes associated with polyposis, with negative results.
Conclusions: The clinical course of cap polyposis remains unclear. The need for and timing of colonoscopy should be individualized based on the number of polyps and symptom severity. Initial treatment should be conservative, focusing on resolving constipation and eradicating H. pylori. In cases with persistent symptoms, endoscopic resection of the lesions should be considered.

Introduction

Quality assessment is a priority in the field of gastroenterology. However, limited data are available from Greece regarding adherence to quality standards in gastrointestinal endoscopy.

Aims & Methods

This study aims at assessing the knowledge and compliance of Greek gastroenterologists with established quality standards for upper and lower digestive endoscopy, while exploring factors that may influence compliance.
​This prospective study recorded data on the quality of upper and lower digestive endoscopy performed in Greece from October 2024 to January 2025. All members of the Hellenic Society of Gastroenterology (n=668) were invited to participate via an electronic survey. The survey included a questionnaire designed specifically for this study, covering demographic and professional characteristics, as well as quality indicators for gastroscopy and colonoscopy.

Results

A total of 164 gastroenterologists participated (response rate 24.55%), of whom 107(65.24%) were male, and 102(62.2%) working in public or academic hospitals. The duration of gastroscopy was not recorded by 116(70.73%) participants, while 102(62.2%) systematically used photodocumentation. Most participants utilized the Prague and Los Angeles classifications 156(95.12%) and 159(96.95%) respectively. Additionally, 140(85.37%) followed the Seattle protocol, and 158(96.34%) conducted biopsies according to ESGE guidelines for precancerous gastric lesions. However, 83(50.61%) don’t use a registry for patients with Barrett’s esophagus. Complications were systematically recorded after gastroscopy by 103(62.8%) and after colonoscopy by 90(54.88%).
In colonoscopy, 149(90.85%) use the BBPS scale, and 158(96.34%) reported successful cecal intubation. Withdrawal times exceeded six minutes for 151(92.07%) participants. An adenoma detection rate of over 25% was achieved by 117(71.78%), while 103(62.8%) consistently used the Paris classification. Proper polypectomy techniques were employed by 111(67.68%), but 100(60.98%) recommended follow-up intervals shorter than guidelines suggest. Patient experience following gastroscopy and colonoscopy was not recorded by 126(76.83%) and 116(70.73%) participants, respectively. Overall, compliance with quality indicators for upper and lower digestive endoscopy was observed in 87(53.05%) and 75(45.73%) participants, respectively. Multivariate analysis revealed that 5-15 years of experience (p=0.05), the use of video recording (p=0.01) and use of high-resolution endoscopes (p<0.01) were associated with improved compliance with quality indicators of upper endoscopy. Whereas age above 55 (p<0.01), use of high-resolution endoscopes(p<0.01), use of video recording (p=0.02) and attendance of educational seminars relevant with quality in endoscopy (p=0.05) were associated with improved compliance with quality indicators of colonoscopy.

Conclusion

In this study, discrepancies were observed in the compliance of Greek endoscopists with endoscopic quality indicators, highlighting the need for further improvement. The systematic recording of these quality indicators is essential, underlining the important role of scientific societies in this process.

Introduction

Managing biliopancreatic disease in elderly patients is a growing challenge, where the balance between benefit and risk becomes increasingly delicate. ERCP remains a fundamental tool, but its application in older adults requires individualized technical and clinical considerations. The aim of our study was to evaluate the characteristics of elderly patients who underwent ERCP.

Aims & Methods

We conducted a retrospective descriptive study from January 2019 to January 2025, including all patients aged ≥65 years who underwent ERCP. Collected data encompassed demographic characteristics, clinical presentation, procedural indications, technical success, therapeutic approaches, and procedure-related complications.

Results

We recorded 186 patients : 62.36% women (n=116) and 37.6% men (n=70), with a median age of 75 years [IQR: 71–80]. The most frequent presenting symptoms were biliary colic (43.4%, n=79), acute cholangitis (23.6%, n=43), cholestatic jaundice (11.8%, n=22), and acute pancreatitis (10.8%, n=20).
ERCP was indicated for benign pathology in the majority of cases, primarily for choledocholithiasis (56.5%, n=104). Other benign etiologies (11%, n=12) included post-cholecystectomy syndrome, biliary pancreatitis, bile duct injury, and Sump syndrome.
Malignant indications included pancreatic head tumors (20.7%, n=38), hilar cholangiocarcinoma (7.1%, n=13), ampullary carcinoma (6.5%, n=12), and gallbladder carcinoma (3.8%, n=7).
The technical success rate for benign pathology was 97.4% (n=113), with a failure rate of 2.6% (n=3). In malignant indications, the success rate was 90% (n=63), with failures (10%, n=7) primarily due to duodenal obstruction or an intradiverticular papilla.
Stenting strategies included uncovered self-expandable metal stents (33.2%, n=43), covered metal stents (3.8%, n=7), and plastic stents (7.6%, n=14).
Intra-procedural bleeding following sphincterotomy occurred in 2.7% of cases (n=3); two were managed with epinephrine injection and one with hemostatic clipping. No delayed post-procedural complications were reported.

Conclusion

ERCP appears to be a safe, effective, and well-tolerated procedure in elderly patients. When guided by appropriate indications and expert technique, age does not represent a limitation but rather a parameter requiring adapted procedural planning.

Clinical Case Summary

A 50-year-old man with known hypertension and hypothyroidism was recently diagnosed with AML. He presented with high-grade fever for one month. There were no gastrointestinal complaints, weight loss, or night sweats. Physical examination was unremarkable aside from fever (38.7°C); he was hemodynamically stable.
Initial labs revealed pancytopenia: hemoglobin 8.4 g/dL, WBC 1.2 × 10⁹/L, platelets 42 × 10⁹/L, and ANC 200/µL. Peripheral smear confirmed febrile neutropenia. He was started on intravenous broad-spectrum antibiotics. Due to persistent fever, a workup for occult infections was initiated. Blood and urine cultures were negative. Serum and BAL galactomannan were positive, suggesting possible invasive aspergillosis; liposomal amphotericin B was commenced.
Abdominal ultrasound revealed a bulky pancreas with heterogeneous echotexture. Contrast-enhanced CT showed a 2×3 cm heterogeneously enhancing lesion in the pancreatic tail. CA 19-9 was normal. EUS identified a hypoechoic.The main differentials considered included: Leukemic infiltration: due to AML background, Primary pancreatic malignancy: suggested by the imaging appearance, Invasive fungal infection: supported by positive galactomannan assays,Pancreatic tuberculosis: rare, but considered due to an endemic background.
FNAC showed granulomatous inflammation with caseation. GeneXpert MTB/RIF was positive for M. tuberculosis.
He was started on anti-tubercular therapy. Fever resolved within 10 days. Imaging at 3 months showed resolution of the mass. He completed a 6-month course uneventfully.
The presence of a discrete mass and lack of gastrointestinal symptoms complicated the diagnosis. FNAC with GeneXpert was key in confirming TB and ruling out other causes.

References

Pancreatic TB is a rare form of extrapulmonary tuberculosis, accounting for less than 5% of abdominal TB cases. It typically affects younger individuals and may be more prevalent in immunocompromised patients, including those with HIV or malignancy.

Clinically, pancreatic TB is a great mimicker. Common symptoms include fever, abdominal pain, weight loss, and night sweats. Jaundice may be seen if there is biliary involvement. Radiologically, it is difficult to distinguish from pancreatic cancer or pancreatitis. Masses may be solid or cystic and can involve any part of the pancreas.

EUS has emerged as a critical tool in evaluating pancreatic lesions. It allows for high-resolution imaging and real-time sampling via FNAC. Cytological examination may reveal granulomatous inflammation, although this is not pathognomonic. A definitive diagnosis often hinges on demonstration of acid-fast bacilli, culture, or PCR-based methods such as GeneXpert.

Our case highlights the importance of considering TB in the differential diagnosis of pancreatic masses, especially in endemic areas or immunocompromised patients. Early diagnosis via EUS-FNA and initiation of ATT can result in complete clinical and radiological recovery, sparing the patient from unnecessary surgical intervention.