Introduction

Irritable bowel syndrome (IBS) is a common gastrointestinal condition with global prevalence ranging between 10-20%. The etiology of IBS is multifactorial and includes low grade inflammation, abnormal neuromodulation, dysbiosis, impaired integrity of the intestinal barrier, activated nociceptive sensory pathways, and dysregulation of the enteric nervous system. Treatment options include dietary modifications, which are limited due to insufficient patient adherence, and essential need for ingredient restrictions. Immune assay guided diet may provide an individualized intervention, which may increase its effectiveness compared with non-personalized dietary strategies.

Aims & Methods

A randomized, double-blind, two-arm trial, comparing the efficacy of Alcat-based personal diet versus a “Sham” balanced diet for eight-week treatment of IBS. The primary outcome was defined as a reduction of ≥50 points on the IBS-severity scoring system (IBS-SSS) [Δ IBS-SSS scores during follow-up]. Secondary outcomes included the raw scores of IBS-SSS, Irritable Bowel Syndrome Quality of Life Questionnaire (IBS-QoL) and the Visual Analogue Scale for Irritable Bowel Syndrome (VAS-IBS). IBS-Adequate Response rate and the rates of moderate / substantial improvement on the IBS Global assessment of improvement (IBS-GAI) and the IBS Global Improvement Scale (IBS-GIS) were documented. We aimed to test the effectiveness of a dietary intervention, based on Leukocyte activation to dietary components test (Alcat, Germany), to direct an individualized immune-based elimination diet.

Results

68 patients with IBS-D (44) and IBS-M (24) were enrolled. Baseline characteristics were comparable between the study groups, except for the higher median IBS-SSS score in the Alcat-group compared with the Sham-group (390 [305-435] vs. 330 [240-390], respectively, p=0.013). At week 8 of dietary intervention, 30/35 (85.7%) patients in the Alcat-group met the primary outcome, compared with 18/33 (54.5%) of the controls (p=0.005). After 8 weeks, there were higher rates of patients in the Alcat-group who reported a significant overall improvement (i.e., positive response, 85.7% vs. 57.6%, p=0.010). Following 8 weeks of dietary intervention, patients in the Alcat group experienced a significant alleviation in abdominal pain (Δ VAS-IBS abdominal pain score of 49.7±29.8 vs. 31.6±28.8, respectively, p=0.020) and a non-significant improvement in diarrheal symptoms (Δ VAS-IBS diarrhea score of 51.0±30.4 vs. 34.4±40.8, respectively, p=0.072), compared with the controls. Performing analysis restricted to patients who were naïve to dietary-intervention, we revealed that these patients were more likely to take an advantage of the Alcat-diet compared with the Sham-diet (ΔIBS-SSS≥50 rate: 100% vs. 57%, respectively, p=0.010), while patients who had previously tried any dietary-intervention were less likely to benefit from the Alcat-diet compared to the Sham-diet (ΔIBS-SSS≥50 rate: 77% vs. 50%, respectively, p=0.148). No serious adverse events were reported during follow-up.

Study outcomes at 8-week time point

Conclusion

Immune-based personalized diet was more efficient than Sham-diet for reducing symptoms in IBS patients, and may serve as a safe treatment option in this population.

Disclosure

This work was partially supported by a research grant from Cell Science Systems GmbH (Alcat Europe).

Clinical Case Summary

A 56-year-old male presented with postprandial vomiting and weight loss beginning three weeks after laparoscopic ulcerorraphy of a perforated pyloric ulcer. An abdominal CT showed marked gastric distension and upper GI endoscopy revealed gastric stasis and a fibrotic stenosis in the duodenal bulb in close relation with a suture stitch, only transposable with an ultra-slim gastroscope. Two sessions of balloon dilation (BD) until 20mm were performed one month apart with poor clinical/endoscopic improvement. Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) was proposed to avoid surgical reintervention.
Using a standard gastroscope a 0.035´´guidewire was passed into the proximal jejunum allowing insertion of a 7-french nasobiliary drain. Jejunal distension was achieved through saline, iodate contrast and methylene blue infusion. The linear echoendoscope was used to identify a distended loop adjacent to the gastric wall and EUS-guided puncture with a 19G needle was accomplished. A 20x10mm lumen-apposing metal stent (LAMS) was deployed in distal gastric body. The flow of blue mixture to the lumen confirmed successful gastroenterostomy creation. The patient was hospitalized overnight and resumed oral feeding the day after the procedure. No symptom recurrence was observed and the gastroenterostomy remained patent during the 6 months of follow-up.
Gastric outlet obstruction (GOO) may result from several malignant and benign causes. Surgical gastroenterostomy, self-expandable metal stents (SEMS) and BD are standard therapeutic options. EUS-GE is emerging as an effective and minimally invasive alternative. EUS-GE presents high technical and clinical success with lower rates of adverse events and reduced need of reintervention when compared to surgery and other endoscopic therapies. In benign GOO, SEMS seems less adequate and BD often results in suboptimal outcomes. The authors exemplify the effectiveness of EUS-GE in a case of GOO associated with a benign condition.

References

Illustrative material:
- Endoscopic and fluoroscopic images of guidewire and nasobiliary drain passed into the proximal jejunum
- EUS image of jejunal distension previous to LAMS placement
- EUS image of LAMS placement
- Endoscopic and fluoroscopic images of LAMS in situ
- Endoscopic image of 6 months follow-up

Introduction

Data evaluating the utility of Blue light Imaging (BLI) and Linked Color Imaging (LCI) in the diagnosis of gastric intestinal metaplasia (IM) and atrophic gastritis (AG) is limited.

Aims & Methods

We aimed to evaluate and compare the diagnostic accuracy of BLI and LCI without magnification for the detection of IM and AG.
Single centre prospective study involving consecutive patients aged ≥18 years undergoing diagnostic upper gastrointestinal endoscopy (UGIE), endoscopic follow-up of intestinal metaplasia or gastric cancer screening. Exclusion criteria: previous gastrectomy, contraindication to UGIE due to comorbidities, no gastric mucosal biopsies, refusal of consent. Endoscopy was initially performed with white light image (WLI), followed by BLI and LCI. Standardized photodocumentation of stomach was performed with WLI, BLI and LCI. Imaging features suggestive of IM: lavender color sign and whitish flat elevation with LCI, and light blue crest and white opaque substance with BLI. EGGIM and Kimura-Takamoto Classification (KTC) were applied when IM and AG were suspected. Systematic random biopsies of the antrum, incisura angularis and corpus along with targeted biopsies of suspicious gastric mucosal lesions were obtained. Histology was considered gold standard. Performance of endoscopic imaging in the detection of IM, AG and EGC was evaluated.
Initially, 134 patients were evaluated and 64 were excluded: previous gastrectomy-22, pending histology-20, non-BLI imaging-15, intolerance to UGIE-3, refusal of consent-1, esophageal stenosis-1 and contra-indication to biopsies-2. Final sample included 70 patients.
Qualitative data expressed as percentage were compared with Chi-square test. A p value of <0.05 was considered significant.

Results

Median age was 56 (19-86), with 49 (63%) female. There was family history of gastric cancer in 12(15%) and history of smoking in 35 (44%).
Histological AG was found in 15 (19%) and IM in 20 (26%) patients. WLI was suggestive of IM in 14(20%), confirmed histologically in 9 (64%). IM was suspected by LCI and BLI in 24 (34%) and 23 (32%) cases, confirmed by histology in 16 (67%) and 17 (74%), respectively.
WLI classified 56 (71%) as EGGIM 0 and after LCI and BLI, 10 (18%) and 8 (15%) of these cases had EGGIM 1 or 2. In 10 patients, EGGIM 1-2 with WLI, only 1 was upgraded to EGGIM 3-4 with LCI and BLI. In 3 (4%) EGGIM 3-4 with WLI, after LCI and BLI,1 had extensive IM (EGGIM 6). Among 19(24%) patients EGGIM 1-2 with LCI, 3(16%) had EGGIM 0 with BLI.
Atrophy was suspected by WLI and LCI in 9(12%) and 15(21%) patients, confirmed by histology in 6(67%) and 8(53%) cases, respectively. According to KTC, 5 (6%) were classified as C1, 2 (3%) as C2 and 4 (5%) as O3 with WLI. With LCI images, 8 (10%) were classified as C1, 3(4%) as C2 and 4(5%) as O3. The sensitivity (Sens), specificity (Spec), accuracy, positive predictive value (PPV), negative predictive value (NPV) of WLI, BLI and LCI in detecting AG and IM are shown in table 1.


Table 1. Sens, Spec, accuracy, PPV and NPV in detecting AG and IM with WLI, LCI and BLI.

Conclusion

Both BLI and LCI are promising advanced endoscopic imaging techniques with BLI having higher accuracy than LCI in detection of IM.

References

1. Chen H, Liu Y, Lu Y, Lin X, Wu Q, Sun J, et al. Ability of blue laser imaging with magnifying endoscopy for the diagnosis of gastric intestinal metaplasia. Lasers Med Sci. 2018 Nov 1;33(8):1757–62.
2. Ono S, Abiko S, Kato M. Linked color imaging enhances gastric cancer in gastric intestinal metaplasia. Vol. 29, Digestive Endoscopy. Blackwell Publishing; 2017. p. 230–1.
3. Ono S, Kato M, Tsuda M, Miyamoto S, Abiko S, Shimizu Y, et al. Lavender Color in Linked Color Imaging Enables Noninvasive Detection of Gastric Intestinal Metaplasia. Digestion. 2018 Nov 1;98(4):222–30.
4. Zhang G, Zheng J, Zheng L, Yu S, Jiang C, Lin W, et al. Gastric intestinal metaplasia assessment between linked color imaging based on endoscopy and pathology. Scand J Gastroenterol. 2021;56(1):103–10.
5. Shu X, Wu G, Zhang Y, Wang Y, Zheng Y, Guo Q, et al. Diagnostic value of linked color imaging based on endoscopy for gastric intestinal metaplasia: a systematic review and meta-analysis. Ann Transl Med. 2021 Mar;9(6):506–506.
6. Esposito G, Pimentel-Nunes P, Angeletti S, Castro R, Libânio D, Galli G, et al. Endoscopic grading of gastric intestinal metaplasia (EGGIM): A multicenter validation study. Endoscopy. 2019;51(6):515–21.

Introduction

Gastrointestinal functional disorders, including irritable bowel syndrome (IBS), are the gastroenterological disorders with the most frequent epidemiology in the general population. Among university students (medical and nursing), there is an increased prevalence of IBS, so much so that it has repeatedly been called a "global challenge." However, despite this, data in such populations are still scarce and not fully represented in all geographic people considering the wide variability that the epidemiology of IBS encounters moving latitude and longitude. In southern Europe and, in detail, in Italy, data in this regard are lacking.

Aims & Methods

In this cross-sectional observational survey study (VANVITELLI-IBS Study), undergraduate medical and nursing students were enrolled and sent an anonymous questionnaire. The latter was sent only after a careful interview with the gastroenterologists included in the study that excluded red flags of organic gastrointestinal disease. Criteria suggestive for diagnosing IBS according to ROME IV were assessed in the questionnaire. In addition, clinic-demographic variables and variables related to university life (i.e., year of study, being on or off campus, possible receipt of scholarships or being in a delayed time-to-degree condition (i.e., outside prescribed time) were collected. In addition, the "Beck Anxiety Questionnaire Inventory" (BAI) and the "PREDIMED questionnaire" were provided. The former assesses anxiety symptoms, the latter the degree of adherence to the Mediterranean diet.

Results

Two hundred and fifty students were considered for enrolment; however, 89 participants were excluded (39 due to flags of non-functional gastrointestinal disorders and 50 refused to take the questionnaire). In the end, 161 patients were included. Of these, 34/161 met the criteria for IBS according to ROME IV [age 22 (21 - 25.25) years, 17 (50%) males and 17 (50%) females, 22 (65.7%) medical students and 12 (35.3%) nursing students] while 127/161 did not [age 22 (21 - 24) years, 59 (46.5%) males and 68 (53.5%) females, 59 (46.5%) medical students and 68 (53.5%) nursing students]. In addition, students who declared Bristol 1-2 stool in more than 25% of cases and Bristol 6-7 stool in less than 25% were 11/34 (32.35%) compatible with IBS-C. Those who declared an inverse percentage ratio (consistent with IBS-D) were 5/34 (14.7%). The remainder of the students (18/34, 52.9%) had a mixed phenotype (IBS-M). The rate of outside prescribed time was higher in IBS-positive than in IBS-negative (29.4% vs 4.7%, p=0.000168), while on the contrary, for that of perceived scholarship (14.7% vs 33.9%, p=0.035). BAI levels were different between positive and negative IBS [17.5 (10.5 - 40) vs 13 (7 - 20), p=0.002] as were those of PREDIMED score [4 (2.75 - 6) vs 7 (3 - 10), p=0.009]. In binary logistic regression, being outside the prescribed time was associated with a higher likelihood of IBS occurrence (OR: 8.403, p=0.000155); the opposite behaviour was for adherence to the Mediterranean diet (OR: 0.258, p=0.002). No correlations between the PREDIMED score and BAI (τ= - 0.38; p=0.493) and no significant changes in BAI (p=0.205) and PREDIMED (p=0.641) as a function of students' year of enrolment were found. More than half of the sample (61.75%) had moderate-to-severe anxiety levels, and 73.52% of the students adhered poorly to the Mediterranean diet in the IBS group.

Conclusion

This study confirms how IBS, in this setting, is a significant epidemiological problem and campaigns in favour of the Mediterranean diet and proper anxiety management could be helpful.

References

- Oka P, Parr H, Barberio B, Black CJ, Savarino EV, Ford AC. Global prevalence of irritable bowel syndrome according to Rome III or IV criteria: a systematic review and meta-analysis. Lancet Gastroenterol Hepatol. 2020 Oct;5(10):908-917.
- Martínez-González MA, García-Arellano A, Toledo E, et al. A 14-item Mediterranean diet assessment tool and obesity indexes among high-risk subjects: the PREDIMED trial. PLoS One. 2012;7(8):e43134.
- Beck AT, Epstein N, Brown G, Steer RA. An inventory for measuring clinical anxiety: psychometric properties. J Consult Clin Psychol. 1988 Dec;56(6):893–7.
- Yang W, Yang X, Cai X, Zhou Z, Yao H, Song X, Zhao T, Xiong P. The Prevalence of Irritable Bowel Syndrome Among Chinese University Students: A Systematic Review and Meta-Analysis. Front Public Health. 2022 Apr 15;10:864721.
- Elmaliklis IN, Liveri A, Ntelis B, Paraskeva K, Goulis I, Koutelidakis AE. Increased Functional Foods' Consumption and Mediterranean Diet Adherence May Have a Protective Effect in the Appearance of Gastrointestinal Diseases: A Case⁻Control Study. Medicines (Basel). 2019 Apr 9;6(2):50.

Introduction

Mediastinal lesions develop from structures located in the mediastinal compartments and the paravertebral areas. The diagnosis of these lesions is primarily based on imaging studies such as computed tomography and magnetic resonance imaging, which confirm the presence of the lesions and suspected metastatic disease

Aims & Methods

This study aims to assess the factors that determine the diagnostic accuracy and yield of endoscopic ultrasound (EUS) in diagnosing mediastinal lesions. This multicenter study involved a list of centres providing EUS services across ten countries all over the globe. The appropriate information was collected regarding EUS-FNA and EUS-FNB procedures, including nature of the lesion, needle types, needle passes, and complications of the techniques. The frequency/percentage conveyed data on the qualitative variables. The p-values were obtained using the Chi-square two-tailed exact test. The significance of the analysis was defined as p<0.05. All the syntheses were performed using the Statistical Package for the Social Sciences (SPSS version 27; SPSS Inc., Chicago, IL).

Results

A total of 439 participants were involved in this study, 255 (58.1%) males and 184 (41.9%) females, with a mean age of 55.7314.93 years. The average accuracy from the valid matched cases between EUS, cytopathy, and final diagnosis (300 out of 331) was 90.63%. EUS-FNA and EUS-FNB diagnostic yield was influenced by needle types, needle size, number of needle passes, and lesion size. Needles with smaller diameters (22G) offered greater diagnostic yield than needles with larger diameters (19G). However, the diagnostic matching accuracy of EUS in relation to needle sizes was statistically insignificant (p= 0.774). A minimal number of needle passes (between 2 and 4) showed a higher diagnostic yield than a higher number of needle passes (>5) with more diagnostic matching accuracy (p = 0.009). EUS-FNB accounted for a 0.5% complication incidence rate each for fever, pain, thoracic pain, and hemorrhage. Patients undergoing EUS-FNA, EUS-FNB, or both procedural examinations had no significant complications (p = 0.085) Table 1.

Table 1: Incidence rate of complications associated with EUS examination techniques

Conclusion

The diagnostic yield of EUS procedures is affected by needle types, number of needle passes, lesion size, and needle size. Besides, EUS-FNA and EUS-FNB are infrequently associated with serious complications, these techniques are safe and offer higher diagnostic yield when utilised responsibly by endosonographers.

References

1- Gadour E, Awad A, Hassan Z, Shrwani KJ, Miutescu B, Okasha HH. Diagnostic and therapeutic role of endoscopic ultrasound in liver diseases: A systematic review and meta-analysis. World J Gastroenterol. 2024 Feb 21;30(7):742-758. doi: 10.3748/wjg.v30.i7.742. PMID: 38515947; PMCID: PMC10950627.
2- Okasha HH, El-Meligui A, Pawlak KM, Żorniak M, Atalla H, Abou-Elmagd A, Abou-Elenen S, El-Husseiny R, Alzamzamy A. Practical approach to linear EUS examination of the mediastinum. Endosc Ultrasound. 2021 Nov-Dec;10(6):406-413. doi: 10.4103/EUS-D-21-00019. PMID: 34854401; PMCID: PMC8785678.