Introduction

Type 1 AIP is the most common presentation of IgG4-related disease. Serum IgG4 levels are widely used in initial screening and diagnosis, with levels ≥135 mg/dL recommended as part of the diagnostic criteria. However, its diagnostic specificity is limited as it can be elevated in a broad spectrum of neoplastic, infectious, and autoimmune diseases. Histological diagnosis though definitive, remains challenging in real life clinical practice. In recent years, IgG4/IgG ratio has been proposed as a promising alternative serum biomarker.

Aims & Methods

We aimed to study the diagnostic utility of serum IgG4/IgG ratio compared to serum IgG4 alone in the diagnosis of Type 1 AIP. We identified a cohort of patients from 2015 to 2021 who had raised serum IgG4 levels in Tan Tock Seng Hospital, Singapore. Associations between serum IgG4 level and IgG4/IgG ratio were compared to confirmed AIP diagnosis and characteristic computed tomography (CT) and magnetic resonance imaging (MRI) features (diffuse pancreatic swelling, rim-like enhancement). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated at IgG4/IgG thresholds of ≥15% and ≥20%.

Results

Our sample included a total of 60 patients with raised serum IgG4 levels. 21 patients had been diagnosed with Type 1 AIP, and 39 patients had not.
The majority of our patients had serum IgG4 ≥135 mg/dL (n=53, 88.3%). However, there was no significant association between the conventional serum IgG4 cut off of ≥135 mg/dL and the diagnosis of AIP (p = 0.687). In contrast, serum IgG4/IgG ratio demonstrated significantly higher values in patients with AIP compared to those without (median 23.2% vs 13.9%; p < 0.001). Analysis by logistic regression of IgG4/IgG ratio showed an acceptable performance with an area under the curve of 0.779, sensitivity of 92.3%, and specificity of 52.4%.

Variable	Type 1 AIP Present (n=21)	Type 1 AIP Absent (n=39)	Test Statistic	p-value
IgG4/IgG ratio	23.2 (24.0 ± 14.2)	13.9 (13.4 ± 4.5)	U = 184	<0.001
Serum IgG4 ≥135 mg/dL	18/21 (85.7%)	35/39 (89.7%)	Fisher's exact	0.687

We performed further analysis to determine a threshold for diagnostic utility of serum IgG4/IgG ratio. A ratio of ≥20% was strongly associated with AIP diagnosis (OR = 13.2, 95% CI: 3.08–56.5; p < 0.001), with high specificity (92.3%) and PPV (78.6%). Reducing the diagnostic threshold to ≥15% increased sensitivity to 76.2% (vs 52.4% at ≥20%) and improved NPV 84.4%, however this reduced specificity to 69.2%.

Subset analysis was performed among patients with Type 1 AIP (n=21) to evaluate for relationship between serum biomarkers and typical imaging findings (diffuse pancreatic swelling, rim-like enhancement). When stratified to a cut off of ≥135 mg/dL, the association between serum IgG4 levels with imaging findings trended towards positivity, but was not statistically significant (OR 3.14, p = 0.0553, φ 0.196). The IgG4/IgG ratio demonstrated a stronger association with typical imaging findings, although still not achieving statistical significance (OR = 1.065, p = 0.129). This subset analysis is likely limited by the small sample size.

Conclusion

This study demonstrates that serum IgG4/IgG ratio is a superior serological marker compared to serum IgG4 alone, particularly in the diagnosis of type 1 AIP. A threshold ratio of ≥20% demonstrated strong association with AIP diagnosis, with high specificity and PPV.
Our findings support the incorporation of IgG4/IgG ratio - particularly at a cut-off of 20% - as a valuable adjunct in diagnosis of suspected type 1 AIP, and we recommend further research in a larger cohort to validate this data.

References

1. Wallace ZS, Naden RP, Chari S, Choi HK, Della-Torre E, Dicaire JF, et al. The 2019 American College of Rheumatology/European League Against Rheumatism classification criteria for IgG4-related disease. Arthritis Rheumatol. 2020;72(1):7–19.
2. Umehara H, Okazaki K, Kawa S, Takahashi H, Yoshino T, Matsui S, et al. The 2020 revised comprehensive diagnostic (RCD) criteria for IgG4-related disease. Mod Rheumatol. 2021;31(3):529–33.
3. Lanzillotta M, Mancuso G, Della-Torre E. Advances in the diagnosis and management of IgG4-related disease. BMJ. 2020;369:m1067.
4. Uchida K, Okazaki K. Current status of type 1 (IgG4-related) autoimmune pancreatitis. J Gastroenterol. 2022;57(10):695–708.
5. Xia CS, Zhang S, Duan L, Zhao CW, Zhang F. Diagnostic performances of serum IgG4 concentration and IgG4/IgG ratio in IgG4-related disease. Clin Rheumatol. 2017;36(11):2769–74.

Introduction

Pancreatobiliary disease during pregnancy, though uncommon, poses significant risks. Gallstone-related disorders affect 3–12% of pregnancies and may progress to life-threatening complications such as cholangitis or biliary pancreatitis. Endoscopic retrograde cholangiopancreatography (ERCP) is a highly effective therapeutic approach; however, concerns about foetal radiation exposure and procedure-related maternal complications limit its broader acceptance. There remains a need for rigorous real-world data on the safety and neonatal outcomes of ERCP during pregnancy.

Aims & Methods

This retrospective observational study aimed to evaluate the safety of ERCP in pregnant patients, focusing on two key outcomes:
(1) Maternal and foetal safety during and after the procedure, and
(2) Effectiveness of radiation-minimisation strategies, including fluoroscopy reduction and abdominal shielding.
We reviewed 25 pregnant patients undergoing ERCP at a tertiary referral centre. Indications included choledocholithiasis (84%), cholangitis (4%), biliary pancreatitis (4%), and stent management (8%). Mean maternal age was 19.2 years; mean gestational age at ERCP was 28.3 weeks. Fluoroscopy usage, post-ERCP complications, Apgar scores, and neonatal follow-up at day 30 were recorded. Fluoroscopy-minimising techniques included suction-verification of bile and stent release without imaging.

Results

No maternal or foetal adverse events occurred peri- or post-procedure. ERCP was performed successfully in all 25 patients, with 23 (92%) undergoing sphincterotomy. Fluoroscopy was utilised in 20 cases (80%), with lead shielding employed in all. In five cases (20%), ERCP was conducted without fluoroscopy by using alternative bile verification techniques. Apgar scores ranged from 7 to 10, and all neonates exhibited normal development at 30-day follow-up.

Parameter	Value
Total procedures	25
Mean gestational age (weeks)	28.3
ERCP with fluoroscopy	20 (80%)
ERCP without fluoroscopy	5 (20%)
Maternal complications	0
Foetal complications	0
Mean Apgar score	9
Sphincterotomy performed	23 (92%)
Normal neonatal development (day 30)	100%

Conclusion

This study confirms that ERCP can be safely performed during pregnancy when executed by skilled endoscopists adhering to radiation-limiting protocols. Fluoroscopy-free ERCP appears feasible in selected cases, significantly reducing foetal radiation exposure without compromising efficacy. Our findings support ERCP as a viable and safe therapeutic option in pregnant patients with biliary obstruction, providing novel evidence for the growing implementation of protective strategies and alternative imaging techniques in high-risk obstetric settings.

References

• Cappell MS, Friedel D. The role of endoscopy in pregnant and lactating women. Gastrointest Endosc Clin N Am. 2020;30(1):69–95.

• Lee SH, et al. Safety of ERCP during pregnancy: systematic review. World J Gastroenterol. 2009;15(4):357–64.

• Ko CW, et al. Complications of ERCP: a prospective study. Gastrointest Endosc. 2007;66(5):1114–9

Introduction

Inflammatory Bowel Disease (IBD), including ulcerative colitis (UC) and Crohn’s disease (CD), is a chronic gastrointestinal disorder characterized by relapsing inflammation and significant psychological burden [1]. Patients with IBD often experience depression, anxiety, and reduced quality of life [2]. However, emerging research highlights posttraumatic growth (PTG)—positive psychological transformation following trauma—as a potential outcome in chronic illness [3].
PTG arises from cognitive restructuring after traumatic events, with rumination playing a key role [4]. Rumination includes intrusive rumination (unwanted, distressing thoughts) and deliberate rumination (purposeful reflection). While deliberate rumination typically fosters PTG, findings on intrusive rumination are inconsistent, with some studies reporting negative, positive, or null effects [5].

Results & Findings

A cross-sectional survey of 237 Chinese IBD patients. Intrusive rumination was negatively associated with PTG (β = -0.33; 95% CI: -0.61, -0.04), with education level impacting this effect (P for interaction < 0.05). Deliberate rumination showed a positive linear relationship with PTG (β = 0.87; 95% CI: 0.57, 1.17). Above a threshold of 17, intrusive rumination had a stronger negative impact (β = -1.01; 95% CI: -1.73, -0.30).

Summary & Discussion

This finding aligns with cognitive theories of trauma processing, which suggest that excessive intrusive thoughts may overwhelm an individual's cognitive and emotional resources, impeding adaptive meaning-making [6]. Below this threshold, intrusive rumination may serve as an initial, albeit distressing, step in cognitive processing, whereas higher levels may entrench negative thought patterns[9].This non-linear association helps reconcile conflicting findings in the literature [7]. Future research should explore whether interventions (e.g., mindfulness, cognitive restructuring) facilitate a transition toward deliberate rumination and subsequent PTG.
In contrast to intrusive rumination, deliberate rumination demonstrated a robust positive association with PTG across all models[8]. For IBD patients, who often experience fluctuating symptoms and emotional distress, facilitating deliberate cognitive processing may help them reframe their illness narrative, enhancing resilience and adaptive coping.
Individuals with lower education levels may lack the cognitive resources and flexibility needed to transform intrusive rumination into constructive meaning-making, making them more susceptible to negative emotional cycles that hinder PTG [9].

Conclusion

In conclusion, a nonlinear relationship between intrusive rumination and PTG in patients with IBD was found. When intrusive rumination exceeded a threshold of 17, it was negatively correlated with PTG. Additionally, deliberate rumination was positively associated with PTG, highlighting its potential as a facilitator of psychological growth.

References

1. Barberio B, Zamani M, Black CJ, et al. Prevalence of symptoms of anxiety and depression in patients with inflammatory bowel disease: a systematic review and meta-analysis. Lancet Gastroenterol Hepatol. 2021;6(5):359-370.
2. Tedeschi RG, Calhoun LG. The Posttraumatic Growth Inventory: measuring the positive legacy of trauma. J Trauma Stress. 1996;9(3):455-471.
3. Joseph S, Murphy D, Regel S. An affective-cognitive processing model of post-traumatic growth. Clin Psychol Psychother. 2012;19(4):316-325.
4. Allen N, Hevey D, Cogley C, et al. A meta-analysis of the association between event-related rumination and posttraumatic growth: the event-related rumination inventory and the posttraumatic growth inventory. J Trauma Stress. 2022;35(6):1575-1585. https://doi.org/10.1002/jts.22875
5. Jones SR, Fernyhough C. Rumination, reflection, intrusive thoughts, and hallucination-proneness: towards a new model. Behav Res Ther. 2009;47(1):54-59.
6. Hill EM, Watkins K. Women with ovarian cancer: Examining the role of social support and rumination in posttraumatic growth, psychological distress, and psychological well-being. J Clin Psychol Med Settings. 2017;24(1):47-58
7. Tedeschi RG, Shakespeare-Finch J, Taku K, et al. Posttraumatic growth: Theory, research, and applications. Routledge. 2018.
8. Niemeyer H, Bieda A, Michalak J, et al. Education and mental health: Do psychosocial resources matter? SSM Popul Health. 2019;7:100392.

Disclosure

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Introduction

The legal responsibility of nurses is a key element in the healthcare sector, especially in complex areas such as digestive endoscopy. This role requires advanced technical skills and a deep understanding of legal implications. Nurses must follow protocols, ethical standards, and laws to ensure patient safety and prevent complications. Despite adherence to protocols, unusual complications can occur. Nurses have an autonomous position of guarantee towards the patient, based on their professional autonomy, which implies an essential task of health protection.

Results & Findings

The systematic literature review examined documented clinical cases in the field of digestive endoscopy, consulting clinical databases for situations where nursing responsibility was crucial. Precise data were obtained to provide specifics on nursing responsibility in endoscopy. However, from the analysis of collected clinical cases and available data, it emerges that about 50%-60% of the responsibilities are attributable to non-compliance with good care practices. Ineffective communication, both within the healthcare team and with patients, represents about 20%-30% of the issues in particularly complex contexts. Finally, suboptimal management of a complex environment, including organizational and technological factors, contributes to the remaining 10%-20% of difficulties.

Summary & Discussion

The results of this review highlight the importance of nursing responsibility in digestive endoscopy. The main cause of liability is the failure to adhere to good care practices, indicating the need to improve training and adherence to protocols. Ineffective communication represents a significant portion of the issues, emphasizing the importance of developing effective communication skills. Finally, suboptimal management of complex environments requires attention to organizational and technological factors to improve the quality of care.

Conclusion

From the clinical cases considered, common issues emerge, including the failure to apply good practices, inadequate consideration of the complex environment in which nurses work, and communication difficulties. These factors impact the quality of care and highlight the need to invest in tools and training. Focusing on effective communication strategies and appropriate protocols could improve nursing responsibility.

References

Endoscopia digestiva e responsabilità dell'infermiere-http//www.Nurse24.it;Endoscopia digestiva e responsabilità dell'infermiere-http//wwwDocsity.com;Survey Nazionale di Anote-Anigea -infermiere online;Irti G, L'infermiere di endoscopia oggi: compiti e responsabilità. Ipasvi Roma 2000; studio centrato sulla letteratura della responsabilità in endoscopia –http//tesi.univpm.it

Introduction

Video capsule endoscopy is a diagnostic method for examination of the small intestine. It is completely non-invasive and painless method that ensures complete examination of the small intestine because the video capsule allows a visual examination of the entire small intestine including parts that are difficult to reach with other endoscopic methods. Capsule provide high-quality images of the inner walls of the small intestine. This allows a better detection of pathological changes such as polyps, inflammation or bleeding. In a certain population of patients there is a risk that capsule "get stuck" in the intestine. This especially applies to patients with previous operations in the small intestine, in those who are on long-term therapy with nonsteroidal antirheumatic drugs, in patients who have had radiation to the pelvic region, or in patients where there is a suspicion of stenosis of the small intestine which is possible in patients with Crohn's disease.

Results & Findings

Patient underwent a small bowel video capsule examination. After the patient did not notice that the capsule had come out of the large intestine he come to our department. We performed a radiological evaluation which determined that capsule had remained in the small intestine. It was suggested to try to remove it through a single balloon enteroscope in order to avoid surgery. He was prepared for single balloon enteroscopy under general anesthesia. The endoscope was advanced through the small intestine to the site where the capsule had remained (middle part of jejunum) and with the help of a net loop the capsule was grasped and safely removed.

Summary & Discussion

One of the common risks of the procedure is capsule retention which is defined as a capsule remaining in the gastrointestinal system for longer than two weeks. Capsule retrieval is not emergent in asymptomatic retainers. In this case, the patient had no symptoms but was concerned because the capsule did not come out as expected. Considering the passage of time since installation and the type of capsule itself it was not possible to see online where the capsule is located. We used a radiological methods to detect capsule retention. Because we gave the patient clear instructions on what to expect after the capsule was placed so the retention condition was recognized in time and the extraction procedure was performed which ultimately resulted in avoiding patient surgery.

Conclusion

In order to avoid potential complications in the form of retention of the capsule in the small intestine in patients with Crohn's disease, before the actual placement of the capsule, the patient can be given a capsule to check the patency of the small intestine. A successful patency test minimizes the risk of retention and allows the safe administration of a capsule. On the other hand single baloon enteroscopy provides us possibility of therapeutic action in the small intestine and using of this endoscopic method spare patient from other invasive solutions.

References

1. Boysen M and Ritter M, Small Bowel Obstruction from Capsule Endoscopy, West J Emerg Med. 2010 Feb;11(1):71–73.
2. Mitselos IV, Katsanos KH, Tsianos, Eliakim R, Christodoulou DK, Clinical Use of Patency Capsule: A Comprehensive Review of the Literature, Inflammatory Bowel Diseases, Volume 24, Issue 11, November 2018, Pages 2339–2347