Introduction

A diverse variety of biologics and small molecules have been developed for the treatment of refractory ulcerative colitis; however, it is still reported that 10% of these patients will undergo surgery within a decade for inadequate induction and maintenance of remission due to reasons such as drug ineffectiveness, loss of response, and side effects. Dual therapy using a combination of biologics has been attempted for rheumatoid arthritis with lack of success, owing to insufficient efficacy and increase in side effects. In inflammatory bowel disease, biologics have been developed against adhesion molecules, which are considered to have high intestinal selectivity and safety, with potential for safe co-administration with other drugs. Carotegrast (AJM300), an oral α4 integrin antagonist, has been developed and approved as a novel therapy for ulcerative colitis, however there have been no reports so far on the dual use of carotegrast with other biologics.

Aims & Methods

We investigated the efficacy and safety of carotegrast in combination with other biologics in treating refractory ulcerative colitis. Six patients (3 males, median age 27 years) who underwent dual therapy with carotegrast and another biologic (4 cases of ustekinumab and 2 cases of infliximab) for treatment refractory ulcerative colitis at the Advanced Clinical Center for Inflammatory Bowel Diseases, Tokyo Medical and Dental University after May 2022 were included, Patient background, short-term efficacy, and safety profile were investigated.

Results

The median pMayo at induction was 5.0 (3-6). 50% of patients were steroid-refractory, 50% were steroid-dependent. 5 patients had inadequate or no response to previous biologics and 1 patient had a loss of response to biologics. The median time between the last dose of biologic and the start of carotegrast was 14.5 days, and the mean duration of carotegrast administration was 38.8 days. Carotegrast was discontinued in one patient due to epigastric pain. All 5 patients who were eligible for continued treatment achieved pMayo0 at 2 weeks, and also maintained pMayo0 at the end of the 6-8 week treatment period, and were placed on maintenance therapy with biologics. No side effects other than epigastric pain were observed.

Conclusion

Dual therapy with carotegerast and another biologic may be effective and safe in ulcerative colitis patients with biologics failure.

Introduction

Fecal incontinence is a diagnosis represented by recurrent uncontrolled passage of fecal material for at least 3 months. It is relatively common, with an assumed prevalence of up to 7% of the worldwide population. The therapy is challenging and often with insufficient clinical results. It should be specifically tailored to different symptom presentations meaning urge or passive incontinence. One of the relatively and therefore not widely used treatment options for incontinence is local sphincter stimulation which is a safe non or minimally invasive method. This stimulation could be performed in at home setting, so it presents a substantial time and cost-saving option for the patient and for the healthcare system. However, the data published on this topic so far are scarce with heterogeneous studied populations and results with no universally accepted treatment protocol.

Aims & Methods

This study aims to evaluate the effect of local sphincter stimulation on the functional parameters of sphincters and symptoms based on the different phenotypes. This is a retrospective single-center study analysis on patients with fecal incontinence (age> 18 years). The duration of the training was 12 weeks, with training once daily for 6 days a week. The parameters of the home stimulation device were as follows: Frequency: 40 Hz; Impulse Width: 0.2 s; Ramp-up time: 1s; Workout time: 6s; Rest: 15s. Training duration: 20min. During the perceived stimulation patients were instructed to squeeze the sphincter. 3D anorectal manometry was performed according to the IAPWG protocol at the initiation visit and the control visit. Clinical evaluation was performed by self-reporting Wexner’s score for fecal incontinence at both visits.

Results

Twenty-three patients (23) were consecutively screened for eligibility and assigned for the therapy. Three patients (3) did not adhere to the training due to various personal reasons one (1) patient did not tolerate stimulation. Therefore, 19 patients (10 passive, 9 urge) completed the full treatment protocol for 12 weeks and were considered for the final analysis. The total average increase in sphincter rest medium pressure was 22.53%, with significantly higher improvement in the urge group compared to the passive group (46.24% vs. 1.18% respectively). The total average increase in sphincter rest maximum pressure was 25.69%, with significantly higher improvement in the urge group compared to the passive group (46.92% vs. 6.59% respectively). The total average increase in sphincter maximum squeeze pressure was 36.13%, with significantly higher improvement in the urge group compared to the passive group (57.82% vs. 16.61% respectively). The average improvement in Wexner score was 3.1 points, with higher improvement in the urge group compared to the passive group (4.2 points vs. 2.1 points respectively).

Conclusion

The home-administered local anal sphincter stimulation for 12 weeks seems to be an effective treatment option for both types of fecal incontinence and significantly more effective in the urge type. Therefore this could be considered as a cost and time-effective treatment option compared to standard office-based therapy. Although a home stimulation device is simple to use, the ability of the patient to adhere to the protocol should be evaluated during the screening process.
Funding: European Parliament and Council Recovery and Resilience Plan of the Slovak Republic 2021 – 2027, code: 09I03-03-V04-00761

Introduction

Patients (pts) with disorders of gut–brain interaction (DGBI) frequently present with overlapping non-gastrointestinal conditions such as fibromyalgia (FM), whose prevalence in irritable bowel syndrome (IBS) varies from 28–33% to 65%. The co-presence of FM complicates clinical management and worsens outcomes. The pathophysiology of IBS is now well established, involving dysfunction of the gut-brain axis and peripheral factors including microbiome alterations, mucosal barrier disruption, and immune activation. Recently, dysfunction of the gut-musculoskeletal axis was proposed for FM. Shared pathophysiology, involving altered intestinal permeability (IP), and multidisciplinary therapeutic strategies, including dietary interventions, have been proposed for both conditions.

Aims & Methods

To evaluate the effects of a low-FODMAP diet (LFD) on clinical symptoms and IP in pts with IBS, FM, or both, and to assess correlations with serum biomarkers.
This prospective study included 35 pts (88,6% female): 45.7% had IBS+FM, 28.6% IBS-only, and 25.7% FM-only. IP was assessed using serum zonulin (ZO) levels. Clinical evaluations included: SF-36 (quality of life, QoL) for all pts; IBS Symptom Severity Score (IBS-SSS) for IBS; and both Fibromyalgia Impact Questionnaire (FIQ) and Polysymptomatic Distress Scale (PDS) for FM. Assessments occurred at baseline (T0), after 1 month of LFD (T1), at 3 months (T2, reintroduction phase), and 6 months (T3, free diet/follow-up).

Results

At baseline, QoL was significantly lower in the IBS+FM group compared to IBS-only, especially in physical functioning, social functioning, and general health domains (p<0.001). The IBS-only group showed global QoL improvement after 1 month on the LFD, with significant gains in general health (p=0.02) and emotional well-being (p=0.002). Improvements were sustained through T2, but did not increase further. In contrast, the IBS+FM group demonstrated delayed but significant improvements at T2 in physical functioning (p=0.01), energy/fatigue (p=0.02), and social functioning (p<0.001) domains. Similarly, IBS-SSS scores improved significantly at T1 in the IBS-only group (p<0.001) and remained low at T2 (p=0.006), while in the IBS+FM group, the improvement occurred later, reaching significance at T2 (p=0.02). For FM, FIQ and PDS scores improved significantly only at T3 in the IBS+FM group (p=0.03 and p=0.006, respectively), while no significant change occurred in the FM-only group. However, in this group of pts a non-significant reduction in FM symptom scores was observed at T1 and T2, but was followed by worsening symptoms during the free-diet follow-up at T3. Serum ZO levels at T0 were similar across all groups. Significant reductions were observed only in the FM-only and IBS+FM pts, both at T1 (p< 0.001 for both) and T2 (p=0.004, p=0.01, respectively), suggesting improved intestinal permeability. No significant ZO changes were instead observed in the IBS-only group.

Conclusion

The low-FODMAP diet improves gastrointestinal symptoms and quality of life in IBS patients, especially in general health and emotional well-being domains, with delayed but significant benefits also in those with FM. Reductions in zonulin levels in FM and IBS+FM groups suggest enhanced intestinal barrier function, though not directly tied to symptom relief. These findings support a role for central sensitization in FM and underscore the importance of a multidisciplinary approach for managing overlapping DGBI and FM.

Introduction

Environmental pollution is significantly driven by endoscopic waste generation. Previous studies have found a range of 0.5 to 3.0 kg of waste per endoscopic procedure depending on the geographical origin.

Aims & Methods

This study aimed to evaluate endoscopic waste generation in hospitals and offices to assess its healthcare system impact and propose waste reduction strategies. A prospective, multicentre, observational study was conducted over four-week periods in two tertiary hospitals and two gastroenterology offices in Germany in 2023. Waste from 2275 patients in 2889 procedures was collected, sorted, and weighed. Recyclable waste was categorised. National waste generation from gastrointestinal endoscopies in Germany was estimated using insurance data.

Results

The mean quantity of waste generated per procedure was 1119 g (hospitals: 1167 g; offices: 1094 g). Office-based procedures generated significantly less solid waste compared to equivalent hospital-based procedures (EGD: -51%, colonoscopy: -50%, their combination: -47% and sigmoidoscopy: -69%, all p < 0.001). Combining consecutive procedures could reduce waste by up to 39% for EGD and colonoscopy and 33% for EUS and ERCP. Waste from suction bags had an impact of 35% per procedure and could be processed via the sewage system instead of being disposed. Replacing single-use gowns with reusable ones could reduce personal protective equipment waste by 54%. Furthermore, 23% of endoscopic waste was potentially recyclable.
Gastrointestinal endoscopies in Germany generate extrapolated 8024 tonnes of waste, annually, equivalent to the annual waste generation of 18533 German citizens. This resulted in a total of 3924 tonnes of greenhouse gas emissions.
This figure corresponded to approximately 33.7 million kilometres driven by passenger cars or 4242 economy flights from Frankfurt to New York. If this waste was recycled according to the present study results with a recycling share of 23%, the waste could have been reduced by the equivalent annual waste generation of 3616 German citizens and a reduction of 1427 tonnes of greenhouse gas equivalents. This reduction would have been equivalent to about 12.3 million kilometres driven by car or 1542 economy flights from Frankfurt to New York.

Conclusion

The mass of endoscopic waste generated in Germany is comparable with the domestic waste of a small town. Implementing a waste reduction system in endoscopic practices, prioritizing prevention, reduction, reuse, recycling, and recovery, could significantly reduce waste generation.

Disclosure

Nothing to disclose by the authors.