Introduction

Upper gastrointestinal bleeding (UGIB) remains a major clinical emergency with significant morbidity and mortality despite advances in endoscopic and medical management. While existing risk scores have been widely used, their applicability to specific populations is limited. We aimed to identify mortality-associated risk factors in Colombian patients with UGIB and propose the "Bogotá Score" as a novel stratification tool tailored to our population.

Aims & Methods

We conducted a retrospective case-control study involving 472 patients with UGIB across three Colombian centres during 2023. Twenty-five (5.3%) patients died due to UGIB-related complications. Demographic, clinical, and endoscopic variables were compared using bivariate analysis. Variables significantly associated with mortality were included in a multivariate logistic regression model. A point-based risk score—the Bogotá Score—was derived from independent predictors.

Results

Age ≥70 years, anaemia (OR 7.15; p=0.022), haemoglobin <10 g/dL, Blatchford score >8 (OR 1.18; p=0.003), hospitalisation delay >24h (OR 1.01; p=0.008), and rectorrhagia were associated with increased mortality. Conversely, melena was linked to reduced risk (OR 0.20; p=0.001). These variables were integrated into the Bogotá Score. Patients were stratified into four risk categories: low (0–3), moderate (4–6), high (7–9), and very high (≥10).

Table: Bogotá Score – Risk Stratification Tool

Interpretation:

• 0–3: Low risk

• 4–6: Moderate risk

• 7–9: High risk

• ≥10: Very high risk

Conclusion

The Bogotá Score represents a simple, evidence-based tool for early risk stratification in UGIB. By incorporating context-specific variables, it enhances clinical decision-making in Latin American settings. Early ICU transfer and intensive monitoring for high-risk groups may improve outcomes. Future multicentre validation is warranted.

References

• Stanley AJ, Laine L, Dalton HR, et al. Comparison of risk scoring systems for patients presenting with upper gastrointestinal bleeding: international multicentre prospective study. BMJ. 2017;356:i6432. This study evaluates the performance of various risk scoring systems, including the Glasgow-Blatchford Score, in predicting clinical outcomes in UGIB patients. ​BMJWikipedia+7Wikipedia – Die freie Enzyklopädie+7Nature+7

• Zou K, Huang S, Ren W, et al. Development and validation of a dynamic nomogram for predicting in-hospital mortality in patients with gastrointestinal bleeding: a retrospective cohort study in the intensive care unit. Scientific Reports. 2024;14:27940. This research presents a predictive model for in-hospital mortality among patients with gastrointestinal bleeding, emphasizing the importance of tailored risk assessment tools. ​Sage Journals+3Nature+3Nature+3

• In KR, Oh YE, Moon HS, et al. Comparison and validation of several scoring systems for non-variceal upper gastrointestinal bleeding: a retrospective study. Scientific Reports. 2024;14:27940. This study compares and validates multiple scoring systems for non-variceal UGIB, highlighting the need for accurate risk stratification in diverse populations.

Clinical Case Summary

A 42-year-old male patient was admitted to our department due to a chronic abdominal pain and symptoms of gut-brain dysfunction (bloatedness, belching, stomach fullness and mixed bowel habits) that lasted for years. He also suffered of ventricular extrasystoles that were more prominent during stomach fullness and for which he underwent two ablation procedures. Five years prior to hospitalization extensive outpatient assessment was performed (laboratory check-up, gastroscopy, abdominal ultrasound, esophageal manometry, 24h pH-metry, occult blood testing, microbiome testing), but, except for insufficient cardia and reduced biodiversity, there were no other pathological findings. The symptomatic therapy was given, but yielded inadequate relief. Due to severe insomnia and worsening of aforementioned symptoms, the patient underwent cognitive behavioural therapy. Although insomnia improved, bloatedness and postprandial pain persisted. At that point, patient contacted our department and was subsequently hospitalized. Extensive laboratory check-up was redone, as well as functional tests, MR enterography and CT scan of the thorax, abdomen and pelvis. Except for distal esophageal spasm and defecatory dyssynergia, findings were normal. Finally, we decided to perform an abdominal vascular ultrasound. An impression in the celiac trunk was noted - especially prominent during the expiration with a peak systolic velocity of 3m/s. Based on the ultrasound finding and clinical scenario, the diagnosis of mean arcuate ligament syndrome (MALS) was established. Surgical decompression procedure was performed and the patient reported improvement in postprandial pain and cessation of bloatedness. Having given the diagnosis, the patient finally entered the way to recovery. However, the issue of determining the optimal timing for integrating symptoms of gut-brain interaction into the framework of rare diagnoses and for modifying the diagnostic approach remains unresolved.

References

1. Image of vascular ultrasound performed prior to decompression procedure
2. Image of postoperative vascular ultrasound - performed 3 months postoperatively

Disclosure

The Authors have nothing to disclose.

Introduction

The etiology of gastroesophageal reflux disease (GERD) is unknown but reflux-induced esophageal injury as a result of cytokine-mediated inflammation has been implicated (1). There is emerging evidence duodenal immune activation may be associated with an increased risk of GERD (2). Celiac disease is strongly associated with GERD which improves upon removal of gluten (3). The duodenum is the first major part of the gut to process food and swallowed aerosol antigens, and is a master controller of upper gut motility. The role of duodenal inflammation in GERD, if any, remains understudied. Assessing T-helper (Th) subsets using chemokine staining has been previously documented and allows the use of archived gut samples (4). We aimed to identify if there is a duodenal Th signal in GERD.

Aims & Methods

Two retrospective case control studies. Study 1; Duodenal biopsies of 3 groups: 1) GERD (n=22), defined as abnormal acid exposure time on 24-pH monitoring, with or without positive symptom association probability (GERD-SAP+ and GERD-SAP-). 2) Healthy controls (n=17): no symptoms, endoscopic or histological abnormalities. 3) Disease controls: Eosinophilic duodenitis (EoD): (n=8). Blinded histological review of duodenal samples to assess cellular and architectural changes. Dual Immunohistochemistry (IHC) was optimized to identify CD4-Th subsets using the chemokine staining patterns: Th1(CD4+CCR4-CCR5+CCR6-), Th2 (CD4+CCR4+CCR5-CCR6-) and Th17(CD4+CCR4+CCR5-CCR6+). Immunofluorescence confirmed co-staining. Dual IHC and blinded quantitative intensity measuring (H-score) were performed using HALO software. Clinical and histological data were collected. One-way Anova was used to compare signal intensity to controls. A positive signal is defined as a statistically significant higher co-staining of CD4-chemokine stain compared to controls. Study 2: Same methods used to assess esophageal T-helper signal in reflux esophagitis (LA Grade B and higher) (RE) (n=16) compared to eosinophilic esophagitis (EoE) (n=31), lymphocytic esophagitis (LE) (n=12) and healthy controls (n=11).

Results

Considering duodenal histopathology (study 1), no differences were found in any of the mean inflammatory cell counts and no architectural abnormalities comparing GERD to healthy controls. Considering duodenal IHC, the CD4 and CD8 intensities were not significantly higher in GERD compared to controls (p=0.96 and 0.96, respectively). GERD- SAP+ demonstrated a significantly higher Th2 intensity than controls (p=0.01), with no difference in Th1(p=0.55) and Th17 intensities (p= 0.27). A significantly higher Th17 intensity was found in EoD (p=0.006). Duodenal Th2 intensity was significantly higher in GERD with a history of atopy (p=0.035), upright reflux (p=0.037), low esophageal contraction amplitude (p=0.0025) and failed peristalsis (p=0.048). Th1 and Th17 intensities were not higher in any of the GERD subgroups compared to controls. Considering esophageal IHC (study 2), CD8 intensity was significantly elevated in RE (p=0.002), but the CD4 intensity was not (p=0.059). RE had a higher Th2 intensity with no difference in other Th markers (p<0.0001). Th-17 intensity was higher in EoE and LE (p=0.0017 and p<0.0001).

Conclusion

A significantly increased duodenal Th-2 signal is found in established GERD when present with a positive symptom association probability, while an increased esophageal Th-2 signal is found in documented reflux esophagitis. The role of immune activation in GERD deserves further investigation.

References

1. Souza RF, Huo X, Mittal V, et al. Gastroesophageal reflux might cause esophagitis through a cytokine-mediated mechanism rather than caustic acid injury.
2. Ronkainen J, Aro P, Walker MM, et al.. Duodenal eosinophilia is associated with functional dyspepsia and new onset gastro-oesophageal reflux disease. Aliment Pharmacol Ther. 2019 Jul;50(1):24-32.
3. Irani MZ, Eslick GD, Burns GL, et al. Coeliac disease is a strong risk factor for Gastro-oesophageal reflux disease while a gluten free diet is protective: a systematic review and meta-analysis. EClinicalMedicine. 2024;71
4.Oki M, Ohtani H, Kinouchi Y, et al. Accumulation of CCR5+ T cells around RANTES+ granulomas in Crohn's disease: a pivotal site of Th1-shifted immune response? Laboratory investigation. 2005;85(1):137-45.

Disclosure

Nicholas J. Talley: Disclosures: GutSee Ltd (consulting microbiome, 2025), Brown University, Agency for Health Care Research and Quality (fiber and laxation) (2024), Rome Foundation (member gastroduodenal committee) (present) Biocodex (FD diagnostic tool) (present) Microba (consulting microbiome - commencing 2025) Comvita Manuka Honey (FD trial consulting) (2025), BluMaiden outside the submitted work. In addition, Dr. Talley has a patent Nepean Dyspepsia Index (NDI) 1998, a patent Licensing Questionnaires Talley Bowel Disease Questionnaire licensed to Mayo/Talley, “Diagnostic marker for functional gastrointestinal disorders” Australian Provisional Patent Application
2021901692, ”Methods and compositions for treating age-related neurodegenerative disease associated with dysbiosis” US Patent Application No. 63/537,725. Boards: The Gut Foundation Board (2025-present), Asia Pacific Association of Medical Editors (APAME) Board (President 2023-2025), Doctors for the Environment (Chair 2024-present), Luminal Faculty GESA (Chair) (2023-2025) Editorial: UptoDate (Section Editor), Mayo Clinic Proceeding Associate Editor (2023-present)
Financial support: Dr. Talley is supported by funding from the National Health and Medical Research Council (NHMRC) to the Centre for Research Excellence in Digestive Health and he holds an NHMRC Investigator grant.

Introduction

Although the overall incidence of colorectal cancer (CRC) has declined in individuals over 50 years of age, CRC in young adults (CRCYA) continues to rise. Previous studies suggest that CRCYA is associated with worse prognosis, primarily due to a higher proportion of advanced-stage disease at diagnosis. Accordingly, early detection and resection of young-onset adenomas (YOAs), the precursor lesions of CRCYA, is critical for prevention. This study aimed to characterize the clinicopathological features associated with YOAs.

Aims & Methods

We retrospectively analyzed patients who underwent colonoscopic polypectomy at our institution between January and June 2020. Neoplastic polyps were evaluated for size, histology, morphology, and anatomical distribution. Comparisons were made between patients aged ≤50 years (YOA group, n = 89) and those aged >50 years (elder group, n = 432).

Results

A total of 958 neoplastic adenomas from 521 patients were analyzed—138 in the YOA group and 820 in the elder group. No significant differences were found in gender distribution, mean polyp size, or morphology. However, elder patients had more neoplastic polyps per person than younger patients (1.90 ± 1.31 vs. 1.54 ± 0.88; p = 0.014).
With regard to anatomical distribution, adenomas in the YOA group were more often located in the left-sided colon compared to those in the elder group (63.3% vs. 45.4%; p < 0.001).
Although the prevalence of advanced adenomas—defined as polyps ≥10 mm, with villous histology, or high-grade dysplasia—was also comparable between both groups. (19.4% vs. 19.9%; p = 0.523), histologically high-risk neoplastic lesions (villous adenoma, high-grade dysplasia, carcinoma in situ, and adenocarcinoma) were more frequent in the elder group (15.7% vs. 7.2%). In contrast, sessile serrated adenomas (SSAs) were more common in the YOA group (23.9% vs. 9.8%; p < 0.001).

Conclusion

While CRC remains more prevalent among older individuals, the comparable prevalence of advanced adenomas between younger and older adults raises concern for early carcinogenesis in young populations. Distinct histological features were observed: SSAs were more frequent in younger adults. Moreover, YOAs were predominantly located in the distal colon. These findings emphasize the need for tailored screening strategies and proactive endoscopic surveillance in younger adults. Future prospective studies are warranted to further clarify the epidemiology and risk profiles of YOAs.

Introduction

Functional and organic bowel diseases in children often present with gastrointestinal (GI) symptoms, yet systematic data on symptom profiles at first presentation limited. Functional bowel disorders (FBD) are common and often require costly and invasive diagnostic procedures. The Pediatric Structured Assessment of Gastrointestinal Symptoms (pSAGIS) is a validated tool that facilitates structured and standardized symptom assessment in pediatric outpatient settings (1).

Aims & Methods

We aimed to compare GI symptoms at first presentation in children with subsequently diagnosed functional (FD), any organic bowel disease (aOD), and specifically inflammatory bowel disease (IBD) using the pSAGIS. The diagnosis of FD was based on the Rome IV criteria (2). From 2016 and 2023, 1550 children completed the pSAGIS questionnaire at their first outpatient visit at St. Anna Children’s Hospital, Vienna. The tool assesses 21 GI symptoms (five grades, from no problem (0) to very severe (4)), grouped into five domains: abdominal pain, dyspepsia, diarrhea, constipation, and dysphagia/nausea. Symptom severity scores (0–12 to 20, depending on the number of items in each domain) were analyzed using median ± SD; p < 0.05 was considered significant.

Results

Of all patients (n=1550), 17.7% (n=274) were excluded due to non-gastroenterological diagnoses. 28.7% (n=445) were diagnosed with FD and 53.6% (n=831) with aOD, including 7.2% (n=111) with IBD. The number of symptoms rated as present (mild to very severe) was 6.4±3.0 SD (FD) vs. 4.8±2.9 SD (aOD) vs. 4.3±2.5 SD (IBD) (FD vs. aOD and vs. IBD: p<0.001). The number of symptoms rated as moderate to very severe was 4.3±3.7 SD (FD) vs. 2.2±3.2 SD (aOD) vs. 2.0±3.1 SD (IBD) FD vs. aOD and vs. IBD: p<0.001).

Symptom scores in all five domains were significantly higher in the functional group:

Conclusion

Children with functional bowel disorders report significantly higher symptom burden at first presentation compared to those with organic disease, including IBD. In addition to its role in long-term monitoring of treatment outcomes, pSAGIS may support early symptom-based differentiation. This could support more targeted diagnostic pathways and inform timely therapeutic decisions in pediatric gastroenterology.

References

(1) Hammer J et al, JPGN 2023; (2) Hyams JS et al, Gastroenterology 2016.

Introduction

The quantitative fecal immunochemical test (FIT) is widely used for colorectal cancer (CRC) screening. While the association between FIT concentration and the risk of advanced colorectal neoplasia (ACN) detection is well established, the predictive performance of current-round FIT concentration alone has limitations. Identifying additional predictive factors could enhance screening. For individuals with a prior colonoscopy, colonoscopy findings and quality metrics may serve as such factors.1 For those who did not undergo colonoscopy due to a negative FIT in the previous round, alternative predictors should be explored. We hypothesized that prior-round FIT concentration could serve as a potential predictor.

Aims & Methods

We aimed to investigate whether prior-round negative FIT concentration could predict CRC and ACN detection by conducting a cross-sectional analysis of data from the FIT arm of the SCREESCO, a nationwide randomized controlled trial on CRC screening in Sweden.1,2 A sample of the Swedish population aged 60 years was randomly assigned to one of three arms: the once-colonoscopy arm, FIT arm, or control arm. Individuals in the FIT arm were invited to undergo two rounds of quantitative FIT screening in the first and third years. A highly sensitive method was used to assess FIT positivity, with a cut-off concentration of ≥10 μg Hb/g feces. We estimated the detection rates of CRC and ACN in second-round colonoscopy based on first-round FIT concentration. Binary regression models were used to assess whether first-round FIT concentration was associated with CRC and ACN detection in the second round. The models included participant characteristics such as sex, body mass index, and smoking status, and second-round FIT concentration, in addition to first-round FIT concentration.

Results

A total of 1,991 individuals were included, with a median FIT concentration of 2.2 μg Hb/g feces (interquartile range: 0.4–4.6) in the first round and 21.8 (13.4–50.8) in the second round. CRC and ACN were detected during second-round colonoscopy in 23 (1.2%) and 267 (13.4%) individuals, respectively. Individuals with first-round FIT concentration of 0–1.9, 2.0–5.9, and 6.0–9.9 μg Hb/g feces had second-round CRC detection rates of 0.8%, 0.9%, and 2.6%, respectively, and ACN detection rates of 9.7%, 12.5%, and 15.9%, respectively. A higher first-round FIT concentration was associated with an increased risk of CRC (risk ratio per unit increase 1.27; 95% confidence interval 1.10–1.47) and ACN (1.08; 1.04–1.12) detection in the second round, after adjusting for the second-round FIT concentration and participant characteristics. For a fixed second-round FIT concentration, the absolute risk of second-round ACN detection increased with higher first-round FIT concentration. For instance, in a nonsmoking or ex-smoking male with a second-round FIT concentration of 20 µg Hb/g feces, the risk increased from 10.0% at < 0.2 µg Hb/g feces in the first round to 14.9% at 5 µg Hb/g feces and 19.6% at 9.9 µg Hb/g feces.

Conclusion

First-round negative FIT concentration is predictive of CRC and ACN detection in the second screening round. Even an increase in low levels of the FIT concentration is associated with future detection of these neoplasms. Incorporating first-round FIT concentration alongside second-round FIT concentration may enhance risk stratification in CRC screening, leading to more efficient use of colonoscopy resources.

References

1. Sekiguchi M, Westerberg M, Löwbeer C, Forsberg A. Gastrointest Endosc. 2025 Feb 4. doi: 10.1016/j.gie.2025.01.037. Epub ahead of print.
2. Forsberg A, Westerberg M, et al. Lancet Gastroenterol Hepatol. 20227: 513-21. doi: 10.1016/S2468-1253(21)00473-8.

Clinical Case Summary

Background: Alcoholic liver disease (ALD) is a major health concern, ranging from hepatic steatosis and alcoholic hepatitis (AH) to cirrhosis, and can progress to acute liver failure (ALF). Extrahepatic manifestations of AH include gastrointestinal bleeding, peripheral neuropathy, and alcoholic cardiomyopathy. However, the association between alcoholic hepatitis and acute inflammatory demyelinating polyneuropathy (AIDP) is rare and scarcely reported.
Case Presentation: A 35-year-old chronic alcoholic female with hypothyroidism presented with jaundice (bilirubin 13.3 mg/dL) and hepatomegaly. Two weeks later, she developed ascending lower limb weakness, absent reflexes, and reduced muscle power (right leg 3+/5, left leg 2/5). Nerve conduction studies were suggestive of demyelinating pathology. Lab workup revealed elevated AST (134 IU/L), ALT (31 IU/L), INR (1.9), and thiamine deficiency (23.7 μg/L). Other potential differentials, including viral hepatitis and autoimmune hepatitis, were ruled out based on negative serology for HBsAg, HCV, CMV, and autoimmune markers (ANA, anti-LKM antibodies). Despite thiamine supplementation and IV immunoglobulin (IVIG) therapy (0.4 g/kg/day for 5 days), the patient showed limited motor improvement. Progressive liver failure and sepsis led to death.
Conclusion: The pathophysiology of AIDP in the context of AH remains unclear but may involve immune dysregulation due to alcohol’s toxic effects on the nervous system. Early detection of AIDP in patients with AH is crucial, as these patients are at risk of respiratory failure and permanent neurological deficits. Although IVIG therapy may offer some improvement, the prognosis remains poor in cases complicated by severe liver failure. This case highlights the importance of recognizing and managing complications like AIDP in patients with AH.