Introduction

Gut micorbiota in patients with cystic fibrosis (pwCF) is severely disrupted and a potential source of further complications. We aim to provide quantitative evidence of the differences in gut microbiota between pwCF and non-CF controls to understand CF gut flora composition and identify potential sites for microbiota modulation with special focus on time-dependent changes.

Aims & Methods

We conducted a systematic review and meta-analysis of PubMed, EMBASE, CENTRAL, Web of Science, and Scopus up to November 13, 2023 (CRD42023482792). Included were case-control studies assessing gut microbial alpha diversity or relative abundance in pwCF and controls without gut-affecting conditions or drugs. Standardized mean differences (SMD) with 95% confidence intervals (CI) were calculated using a random-effects model for both outcomes. We performed subgroup analysis for alpha diversity for infants, children, and adults. We used the Joanna Briggs Institute risk of bias tool.

Results

Among 2550 studies, 11 met inclusion criteria (enrolling 1174 subjects). Alpha diversity analysis showed age-specific changes. Observed OTUs were non-significantly decreased in adult pwCF compared to controls (SMD=-1.57; 95%CI -4.21 to 1.08, across 3 studies, 80 pwCF and 100 controls). Children with CF displayed a significantly reduced Shannon index (SMD=-1.43; 95%CI -2.06 to -0.79, across 3 studies, 77 pwCF and 78 controls). However, in infants, no difference was detected in Shannon index between CF patients and controls (SMD=0.05; 95%CI -0.74 to 0.84, across 4 studies, 288 pwCF, 519 controls). Analysis of follow-up data in infants revealed a decreasing tendency of Shannon index in pwCF compared to controls during the first year of life (SMD=0.67; 95%CI -1.20 to 2.54 at 4 months vs. SMD=0.45; 95%CI -1.81 to 2.71 at 6 months vs. SMD=-0.61; 95%CI -1.98 to 0.75 at 12 months). A significant increase in the relative abundance of Veillonella and E.coli marked the CF group with a noticeable increase of Enterobacter and decrease of Bacteroides and Faecalibacterium compared to controls (see Table).

Conclusion

Gut microbial alpha diversity is reduced in adults and children with CF compared to controls, while infants with CF exhibit similar diversity, which continuously decreases during the first year of life. Perturbations in the intestinal microbial ecosystem are defined by a significant increase in E.coli and Veillonella abundances within individuals with CF compared to controls enabling specifically targeted microbiota modulation.

Clinical Case Summary

Intra-ampullary papillary tubular neoplasms (IAPNs) are rare neoplastic intraepithelial lesions that occur within the ampulla. Given their well-documented malignant potential, early recognition and intervention are paramount to prevent malignant transformation. We present a case of IAPN successfully managed via endoscopic papillectomy.
A 58-year-old male was incidentally found to have a bulky-appearing ampulla of vater during esophagogastroduodenoscopy as part of routine health screening. Endoscopic ultrasonography revealed a 20-mm hyperechoic lesion at the ampulla, with histopathological evaluation demonstrating low-grade dysplasia (indeterminate for neoplasia). Laboratory investigations, including hematological parameters, biochemical profiles, and tumor markers, were within normal limits. Contrast-enhanced abdominal CT demonstrated a well-defined, homogeneously enhancing 20-mm lesion at the ampullary region without biliary/pancreatic duct dilation.
Endoscopic papillectomy was performed using a duodenoscope with snare. Prophylactic stents were placed in both the biliary and pancreatic ducts to ensure adequate drainage. Any intraprocedural bleeding was promptly controlled with hemoclip application. Histopathological analysis confirmed high-grade IAPN, characterized by a polypoid tumor with closely packed tubular glands lined by pseudostratified columnar epithelium showing loss of polarity and moderate nuclear atypia (Ki-67 index: 50%). The postoperative course was uncomplicated, with discharge achieved on the sixth postoperative day. At six-month follow-up evaluation, surveillance endoscopic ultrasonography showed no evidence of recurrence.
IAPN represents a distinct neoplastic ampullary entity within the spectrum of ampullary tumors. While endoscopic resection demonstrates therapeutic efficacy, its implementation requires advanced endoscopic expertise in specialized centers.

References

Endoscopic ultrasonography revealed a 20-mm hyperechoic lesion at the ampulla
Endoscopic papillectomy was performed using a duodenoscope with snare. Prophylactic stents were placed in both the biliary and pancreatic ducts to ensure adequate drainage. Any intraprocedural bleeding was promptly controlled with hemoclip application.
Histopathological analysis confirmed high-grade IAPN, characterized by a polypoid tumor with closely packed tubular glands lined by pseudostratified columnar epithelium showing loss of polarity and moderate nuclear atypia (Ki-67 index: 50%).

Clinical Case Summary

Introduction: Dieulafoy lesions account for less than 2% of gastrointestinal bleeds, and only 20% of these occur outside the stomach. We present a rare case of a bleeding ampullary Dieulafoy lesion with technical difficulties in management, starting with a standard forward-viewing gastroscope, subsequent use of a side-viewing duodenoscope, and eventually endoscopic retrograde cholangiopancreatography (ERCP) and stenting to allow for safe haemostasis with argon plasma coagulation (APC).
Case report: A 56-year-old male was admitted with pneumonia and fluid overload in the context of end-stage renal disease from poorly controlled diabetes mellitus and hypertensive nephrosclerosis on regular haemodialysis. He was on dual anti-platelet therapy with aspirin and ticagrelor for a recent cardiac stent.
Five days into his admission he was noted to have melena with a haemoglobin drop from 87 g/L to 56 g/L, with a urea rise of 23.9 mmol/L from a baseline of 11.0 mmol/L.
Subsequent gastroscopy revealed active bleeding from the major ampulla without any underlying ulcer or tumour, superior to the biliary orifice, consistent with an ampullary Dieulafoy lesion. The duodenoscope was then introduced for a better view and access to the major ampulla. APC was attempted at 0.8 L/min at 30 Watts due to the size and location, but haemostasis was unsuccessful.
The decision was made to proceed to ERCP and biliary stenting to prevent complications from heat injury to the bile duct and possible pancreatitis. A 7 Fr by 4 cm double pigtail biliary plastic stent was placed into the common bile duct. APC was re-applied at 0.8 L/min at 30 Watts at the bleeding spot with successful haemostasis.
Discussion: This case report aims to highlight the rare occurrence of duodenal ampullary Dieulafoy lesions and the need for prompt recognition and use of resources such as side-view duodenoscopy and ERCP for safe therapeutic management.

Disclosure

None

Clinical Case Summary

The endoscopic removal of polyps located at the appendiceal orifice is a challenge, particularly when extending inside the appendiceal lumen, due to its anatomic difficulty and risk of complications.
The endoscopic full-thickness resection (FTR) technique has become an non-surgical option for these lesions but with a non negligible risk of appendicitis.
With the present case we explore an alternative technique.
A 75-year-old man with iron deficiency anemia underwent upper digestive endoscopy and colonoscopy.
The upper digestive endoscopy was normal.
In the colonoscopy angiectasias were found in the cecum and multiple polyps in the left colon (the largest measuring 30 mm). The inspection of the appendix revealed an intra-appendiceal orifice lesion (Image A).
Only after inversion of the appendix it was possible to accurately assess the lesion: an approximately 15 mm sessile polyp (Images B, C).
We applied argon plasma for ectasias ablation and removed the left colon polyps by endoscopic mucosal resection.
Intra-appendiceal orifice polyp resection was performed underwater with a diathermic loop (Image D), with no immediate or late complications.
Histology revealed a sessile serrated adenoma with low-grade dysplasia.
The described technique, being a simpler, faster and cheaper option than the endoscopic-FTR is a valid and a cost effective one.

Introduction

Ulcerative colitis (UC) is a chronic inflammatory disease requiring sustained therapy for both induction and maintenance of remission. Biologics radically changed the natural history of UC patients and are still the cornerstone of treatment, but they have some limitations. The introduction of oral Janus kinase inhibitors (JAKi), recently approved for UC management, presents a novel treatment option. Data are needed to confirm their efficacy in a real world setting.

Aims & Methods

In this retrospective, observational study at the IBD Unit in Bologna, we enrolled consecutive UC patients treated with the JAKi tofacitinib (TOFA) and upadacitinib (UPA). We collected demographic and disease-specific data, assessing clinical activity via the partial Mayo (pMayo) score, biomarker status through C-reactive protein levels, and endoscopic activity via the Mayo endoscopic score at baseline and at 2, 6, and 12 months. Concomitant use of steroids were registered at every time point. We measured clinical response (≤3-point reduction in pMayo or discontinuation of steroids) at 2 months, clinical remission rates (pMayo < 2) and endoscopic remission (Mayo score of 0) at each time point. Need for surgery was also recorded.

Results

A total of 50 patients were treated with JAKi between December 2021 an June 2023 (39 TOFA and 11 UPA). Males were 59.57% and median age was 35.5 years. Nobody were bio-naïve and 80.86% were exposed to ≥ 2 biologics/small molecules prior to JAKi initiation. Concomitant steroids were present in 76% of cases at baseline. Clinical response at T2 was obtained in 65.30% of cases. Clinical remission rate was 40% at T2, 32.6% at T6 and 24.4% at T12. Endoscopy was performed at T2 in 24 patients, at T6 in 26 and at T12 in 10 patients; endoscopic remission was observed in 5/24, 9/26 and 4/10, respectively. Treatment optimization was adopted in 52% of cases. A total of 5 patients (10%) underwent colectomy during follow up period. No serious adverse events were observed.

Conclusion

In a cohort of multirefractory UC patients, JAKi demonstrated substantial efficacy in inducing clinical and endoscopic remission, though there was a decline in effectiveness during the maintenance phase. The rate of colectomy remained relatively low, underscoring the potential utility of JAKi in this challenging patient population.

Introduction

Endoscopic papillectomy(EP)is a viable treatment option for ampullary lesions(AL).While many studies have reported low morbidity and acceptable outcomes, early attempts to pool data from these initial experiences have produced conflicting conclusions regarding key technical aspects. To address these uncertainties, we conducted a systematic review and pooled analysis to evaluate the safety and efficacy of EP for AL,identifying factors that may influence outcomes.

Aims & Methods

Electronic databases(Medline, Scopus and EMBASE)were searched up to September 2024. Studies that included patients with endoscopically resected AL were eligible. Efficacy and safety outcomes were pooled by means of a random-effects model to obtain a proportion with a 95% confidence interval(CI). Univariable meta-regression analyses were conducted to explore potential factors affecting outcomes.

Results

A total of 60 studies(4,859 lesions)published between 2002 and 2024 were analyzed. Complete resection was achieved in 86.2%of cases, though intraductal involvement limited success. The recurrence rate was 18.6%, however, the majority(89.3%)of patients were managed endoscopically without surgery. The pooled adverse event(AE)rate was 30.0%, with bleeding(12.2%)and post-procedural pancreatitis(11.1%)being the most common complications. Prophylactic stenting reduced pancreatitis risk, while intraductal involvement increased perforation risk.Adjunctive treatments for intraductal involvement were associated with an increased risk of papillary stricture.

Conclusion

Endoscopic papillectomy is a safe and effective treatment for ampullary lesions. However, lesions with intraductal extension pose a higher risk of incomplete resection and perforation, warranting careful evaluation of the benefit-risk balance in these cases. While prophylactic pancreatic stenting may reduce the incidence of post-procedural pancreatitis, optimizing strategies to minimize overall adverse events remains a key focus for future research.

Introduction

Helicobacter pylori is a common cause of peptic ulcers and gastritis. Standard triple therapy includes a PPI with amoxicillin and either clarithromycin or levofloxacin. Rising antibiotic resistance has reduced its effectiveness. Sequential therapy offers a phased alternative with better outcomes in resistant cases.

Aims & Methods

To evaluate and compare the efficacy of clarithromycin and levofloxacin-based triple and sequential therapies for Helicobacter pylori (H. pylori) eradication in a resource-limited setting, in the context of emerging antibiotic resistance.
A prospective, randomized study was conducted at a tertiary care center from January 1, 2022, to January 1, 2025. A total of 300 treatment-naïve patients aged 18–60 years, diagnosed with H. pylori infection through stool antigen, urea breath test, or histology, were included. Patients with prior eradication therapy or recent antibiotic use were excluded. Participants were randomized into four equal groups (n=75 each):

• Clarithromycin-based triple therapy (amoxicillin, clarithromycin, PPI)
• Levofloxacin-based triple therapy (amoxicillin, levofloxacin, PPI)
• Clarithromycin-based sequential therapy (amoxicillin + PPI for 5 days, followed by clarithromycin + tinidazole + PPI for 5 days)
• Levofloxacin-based sequential therapy (amoxicillin + PPI for 5 days, followed by levofloxacin + tinidazole + PPI for 5 days) Therapeutic response was assessed post-treatment for eradication.
  

Results

Out of 300 patients (180 males, 120 females), eradication was achieved in:

• 48/75 (64%) in clarithromycin-based triple therapy
• 53/75 (70.7%) in levofloxacin-based triple therapy
• 51/75 (68%) in clarithromycin-based sequential therapy
• 61/75 (81.3%) in levofloxacin-based sequential therapy

All patients completed therapy without notable adverse events or compliance issues. Lower eradication rates in clarithromycin-based regimens suggest rising resistance.

Conclusion

Levofloxacin-based sequential therapy demonstrated the highest eradication rate, highlighting its potential as a preferred regimen in settings with rising clarithromycin resistance. Clarithromycin-based treatments showed suboptimal outcomes, emphasizing the need for region-specific antibiotic stewardship and resistance surveillance.

References

1. Kim JS, Kim BW, Hong SJ, Kim JI, Shim KN, Kim JH, Baik GH, Kim SW, Song HJ, Kim JH. Sequential Therapy versus Triple Therapy for the First Line Treatment of Helicobacter pylori in Korea: A Nationwide Randomized Trial. Gut Liver. 2016 Jul 15;10(4):556-61. doi: 10.5009/gnl15470. PMID: 27114421; PMCID: PMC4933415.
2. Chang, J.Y., Shim, KN., Tae, C.H. et al. Triple therapy versus sequential therapy for the first-line Helicobacter pylori eradication. BMC Gastroenterol 17, 16 (2017). https://doi.org/10.1186/s12876-017-0579-8