Introduction

A large proportion of people with DGBI in the general population, including irritable bowel syndrome (IBS) and functional dyspepsia (FD), do not seek healthcare (HC) for their condition, but their reasons are poorly understood. We aimed to develop a questionnaire to assess different reasons an individual may not consult a doctor for current gastrointestinal (GI) symptoms.

Aims & Methods

The Reasons for Not Seeking Healthcare (RNSH) questionnaire was created from content derived from 8 focus groups with 23 DGBI patients in the United States and Australia and guided by author experience. Participants rated how important each of 21 items is in causing them not to see a doctor for current (within the last 3 months) GI symptoms on a 4-point Likert scale (Not at all, A Little, Moderately, Very). Adults in 9 countries (Canada, China, Germany, Japan, Mexico, Poland, Romania, Spain, United States) completed an online survey including the RNSH, the Rome IV Diagnostic questions for IBS and FD, and questions about medical history, HC utilization, and demographics. Respondents who experienced gastroduodenal or bowel symptoms in the past 3 months but had not sought care for those symptoms were included in Exploratory Principal Component Factor Analysis (PCFA) with Promax rotation evaluating the structure and potential sub-scales of RNSH. Items for each factor were summed and transformed into equal 0-100 sub-scales. Reliability of the RNSH was also assessed.

Results

A total of 17,663 adults completed the online survey and 12,666 (80%) of those had GI symptoms in the last 3 months but had not sought care for them: 51% female; mean age 45.5 years (SD=16.3); 5.7% had Rome IV IBS and 10.7% had FD. Of these, 73.7% had never sought care for digestive problems. The RNSH questionnaire demonstrated very good internal consistency (Cronbach α= 0.88) and split-half reliability (Guttman λ²= 0.89). PCFA yielded 3 factors; 4 items were removed due to poor loading. Reasons for not seeking care include: “negative HC expectations”, “prefer non-medical alternatives”, and “prefer a wait-and-see approach”. The 3 factors collectively accounted for 48% of the variance (Adjusted R²) in RNSH score. The strongest factor keeping people from seeking HC for GI symptoms (highest standardized mean subscale score) was adopting a “wait and see” approach (Table). People meeting Rome IV criteria for IBS or FD were markedly more likely to avoid seeking care due to negative HC expectations than those who did not meet Rome criteria (p<.001) with a medium effect size (d=0.48) and to prefer using non-medical alternatives (p<.001) with a small effect size (d=0.29). No differences existed between the two groups for preferring a wait-and-see approach (p=.087).

Table. Factor Structure with Mean Adjusted Scores for the Three Sub-Scales of the RNSH

				Mean Adjusted Score [95% CI]
Subscale	Items	Eigenvalue	Variance	All (N=12,666)	No IBS or FD (N=11,038)	IBS or FD (N=1,628)
Negative HC Expectations	8	6.46	19.6%	29.97 [29.6-30.4]	28.61 [28.2-29.0]	39.21 [38.1-40.3]
Prefer Non-medical Alternatives	5	2.21	14.7%	27.84 [27.4-28.2]	27.00 [26.6-27.4]	33.51 [32.4-34.6]
Wait and See Approach	4	1.41	13.6%	51.26 [50.7-51.6]	50.99 [50.5-51.5]	52.26 [51.1-53.4]

Conclusion

This study identified, and showed the relative importance of, three distinct factors that keep people from seeing a doctor for their current digestive symptoms. Specifically, people with IBS or FD may avoid seeking HC based on negative expectations for such care or prefer to use alternative methods such as diet modification or stress reduction techniques. The RNSH may be useful for identifying and helping to overcome specific barriers to timely DGBI treatment that may lead to poorer outcomes.

Clinical Case Summary

We report a case of Intrahepatic Cholestasis of Pregnancy (ICP) leading to a rejections of a living, related donor liver two years after the liver transplantation (LT). The 36yo patient underwent LT in November 2021 in Mongolia due to a HBV/HDV related liver cirrhosis. Until August 2024, she had normal test results when she presented with severe pruritus and jaundice at 16-17th week of her second pregnancy. The ICP was diagnosed after elevated total bile acids were detected. A medical pregnancy termination was induced with subsequent three sessions of plasmapheresis. The patient's condition deteriorated further before she received her second living, unrelated donor LT in December 2024.
.

	2023.07.03- prior to pregnancy	2024.08.18- during the pregnancy	2024.09.30- A month after termination	2024.11.04	2025.02.02- Two months after re-transplantation
Total bilirubin (mg/dL) /norm 0-1.2/	1.5 N	17.6 H	20.2 H	40.6 H	0.73 N
GOT/GPT (IU/mL) /norm 0-40/	11.3/18.3 N	265.3/196.1 H	79.5/77.1 H	262.5/113.1 H	6.2/7.6 N
Total bile acids (umol/mL) /norm 0-10/		170.2 H	332 H		7 N

The explant histology stated a massive hepatocellular necrosis (fulminant), total bile duct loss, massive cholestasis (canalicular and intracellular), allograft arteriopathy: Foamy histiocytes in the intimal artery, Arteriosclerosis and Lumen narrowing. No genetic test was performed , either prior or after the LTs. The final diagnosis: An Intrahepatic Cholestasis of Pregnancy leading to a liver graft rejection.
The ICP is a relatively common pregnancy related condition (0.2-2% of pregnancies in Europe and Americas¹) that presents with jaundice and pruritus. The condition usually improves after delivery/termination. In rare cases elevated serum bile acid levels lead to fetal abnormalities or loss of pregnancy. Since the patients condition did not improve after the pregnancy termination in September, 2024, Progressive Familial Intrahepatic Cholestasis (PFIC) was suspected when she admitted her first pregnancy was also complicated by ICP. Better history taking is needed to prevent graft rejection due to bile acid transport dysfunction.

References

1- Williamson, C. and V. Geenes, Intrahepatic cholestasis of pregnancy. Obstet Gynecol, 2014. 124(1): p. 120-133

Clinical Case Summary

MELAS syndrome (Mitochondrial Encephalomyopathy, Lactic Acidosis, and Stroke-like episodes) is a rare mitochondrial disorder characterized by multisystem involvement, particularly in the neurological, cardiovascular, and gastrointestinal (GI) systems. GI manifestations are less commonly discussed but can present significant clinical challenges, including dysmotility, bowel ischemia, and obstruction.
A 19-year-old male, with a family history of MELAS affecting multiple relatives, was admitted with status epilepticus and other associated neurological and cardiovascular symptoms. On admission, the patient exhibited severe metabolic acidosis and elevated lactate levels, raising suspicion for mitochondrial dysfunction. During his ICU stay, he was found to have significant GI symptoms, including a post-operative ileus likely secondary to dysmotility syndrome associated with MELAS. He was subsequently diagnosed with a faecal bezoar causing large bowel obstruction (LBO) in the sigmoid colon, requiring laparotomy with disimpaction of the faecal mass, and decompression of the small and large bowel. There was evidence of bowel ischemia during the surgical exploration, with friable mucosa and necrotic areas observed in the proximal rectum and descending colon. Fortunately, all bowel sections were viable after decompression, and no further ischemic damage was noted.
This case highlights the importance of considering gastrointestinal complications, such as fecal bezoars and bowel ischemia, in patients with MELAS syndrome. GI manifestations, though less commonly recognized, can lead to significant clinical issues such as bowel obstruction and ischemic damage. Early intervention, including surgical management and decompression, is crucial to preventing further complications. Awareness of these potential issues is essential for clinicians managing patients with MELAS, as prompt treatment can improve outcomes and mitigate the risk of severe long-term GI dysfunction.

References

1. Colonoscopy images of diffuse friable mucosa with necrosis in sigmod colon and descending colon

Introduction

Gallstone disease affects approximately 6% of the global population. Adequate knowledge about gallstone disease among the public can facilitate early medical consultation and enable them to navigate healthcare pathways effectively. In the digital age, patients increasingly turn to the internet for health-related information, with over half of the global population relying on it for access to knowledge.

Aims & Methods

This study aimed to evaluate the quality, readability, usability, and reliability of patient-oriented websites providing information on gallstone disease, using validated assessment tools. The three most widely used search engines, Google, Yahoo, and Bing were searched employing keywords related to gallstone disease. The first 50 search results per keyword per engine were screened. Applying the inclusion and exclusion criteria, 52 websites were selected for detailed analysis. The information was assessed for readability using the Flesch Reading Ease Score (FRES), for usability and reliability using the LIDA tool, and for overall quality using the DISCERN instrument. Statistical analysis was performed using SPSS (v27), with significance set at p < 0.05.

Results

Among the 52 websites analyzed, only sixteen (30.8%) sites had obtained Health on the Net (HON) code certification. The median FRES score of the included websites was 60.5 out of 100 (range: 33-79.6), indicating readability appropriate for readers aged 13–15 years. The median LIDA usability and reliability scores were 40 out of 54 (range: 31–54) and 24.5 out of 51 (range: 10–51), respectively. The median DISCERN score was 69.8 out of 80 (range: 30-80) with 5.8% (n=3) of websites scoring below 50%. A low DISCERN score (≤ 50%) was found in three (5.8%) websites. The DISCERN score was found to be significantly associated with LIDA reliability and LIDA overall scores (p < 0.001), government run websites (p= 0.028) and HON code certification (p = 0.01). However, no significant association was found between DISCERN scores and LIDA usability or FRES. Most websites (86.5%) provided accurate clinical information, but only 76.9% discussed treatment complications.

Conclusion

The quality of online patient information on gallstone disease varied considerably, with only a minority meeting optimal standards for readability and certification. While clinical accuracy was generally satisfactory, gaps remain in presenting treatment risks and maintaining content currency. These findings emphasize the need for improved oversight and standardization of online health content to support patient education and informed decision-making.

References

1. Internet World Stats. Internet world stats: Usage and population statistics, http://www.internetworldstats.com/stats.htm (2013, accessed 16 June 2023).
2. Lee JS, Seo HS, Hong TH. YouTube as a source of patient information on gallstone disease. World J Gastroenterol 2014; 20: 4066–4070.
3. Raptis DA, Sinanyan M, Ghani S, et al. Quality assessment of patient information on the management of gallstone disease in the internet. HPB 2019; 21: 1632–1640.
4. European Association for the Study of the Liver. EASL Clinical Practice Guidelines on the prevention, diagnosis and treatment of gallstones. J Hepatol 2016; 65: 146–181.

Disclosure

There is no conflict of interest

Introduction

Endoscopic scores are crucial for assessing Crohn's disease (CD) severity, guiding therapy, and monitoring progression. The Simplified Endoscopic Score for Crohn's Disease (SES-CD) is widely used for this purpose [1]. Accurate scoring is vital for patient care. Recently, artificial intelligence has demonstrated potential in medical image interpretation [2]. This study aims to evaluate ChatGPT's effectiveness in rating the SES-CD.

Aims & Methods

This retrospective study evaluated ChatGPT's accuracy in assessing CD endoscopic activity using the SES-CD. One representative still image was selected for each bowel segment, and stricture degrees were provided separately if present. ChatGPT scored the SES-CD based on these images. The IBD expert's ratings were validated by calculating the intra-class correlation coefficient (ICC) with clinical trial central readers. The ICC between the IBD expert and ChatGPT scores was calculated to determine ChatGPT's reliability in SES-CD scoring.

Results

Nine (mean age 32.0 ± 11.8 years, 77.8% male) were included, with 45 bowel segments. Three (33.4%), 5 (55.6%), and 1 (11.1%) had nonstricturing nonpenetrating, structuring, and penetrating disease, respectively. Four (44.4%) had ileal disease and 5 (55.6%) had ileocolonic disease. Five (55.6%) had previous IBD surgery.
The SES-CD scores of the participants, rated by IBD expert in the hospital, revealed the following mean and standard deviation for each segment of the bowel: 6.9 ± 2.3 in the ileum, 1.3 ± 2.6 in the right colon, 1.6 ± 2.4 in the transverse colon, 1.3 ± 2.6 in the left colon, and 1.3 ± 2.6 in the rectum. The total SES-CD score was 12.4 ± 10.9. The score reliability of the institute IBD expert was tested compared to the clinical trial central reader and an intraclass correlation coefficient was calculated and found to be 0.96 (95% CI, 0.84-0.99) which is considered extremely correlated.
The mean and standard deviation of ChatGPT score in each segment were: 6.4 ± 2.4 in the ileum, 2.4 ± 3.8 in the right colon, 0.9 ± 2.7 in the transverse colon, 0.3 ± 1.0 in the left colon, 0.6 ± 1.3 in the rectum, with total SES-CD score of 10.6 ± 6.8. The calculated ICC between the expert and ChatGPT obtained SES-CD scores was 0.80 (95% IC, 0.64- 0.89) which is considered highly correlated.

Conclusion

Despite being based on only one photo per segment, ChatGPT demonstrated satisfactory performance in estimating endoscopic activity in CD. The differences between the IBD expert obtained scores and ChatGPT scores were acceptable, suggesting that artificial intelligence has the potential to be a useful tool in clinical and research settings, providing an accurate estimation of disease severity based on limited visual data.

References

1- Daperno M, D'Haens G, Van Assche G, et al. Development and validation of a new, simplified endoscopic activity score for Crohn's disease: the SES-CD. Gastrointest Endosc. 2004;60(4):505-512.
2- Levartovsky A, Albshesh A, Grinman A, et al. Enhancing diagnostics: ChatGPT-4 performance in ulcerative colitis endoscopic assessment. Endosc Int Open. 2025;13:a25420943. Published 2025 Mar 14.

Clinical Case Summary

Endoscopic ultrasound (EUS) is currently the diagnostic cornerstone for pancreatic lesions. However, its intraoperative use remains rarely documented and limited to unplanned, ad-hoc scenarios. We present a novel case series in which intraoperative EUS was systematically planned and executed as part of pancreatic tumor surgery.
Case 1: A 35-year-old male with hyperinsulinemic hypoglycemia and inconclusive imaging. EUS identified a 5 mm lesion in the pancreatic head. Intraoperative EUS confirmed its location and ruled out other lesions, enabling a focused pancreatoduodenectomy and minimizing unnecessary resection.
Case 2: A 54-year-old female with a branch-duct IPMN and mural nodule. Intraoperative EUS confirmed multiple cysts and precisely localized the dominant lesion, allowing real-time adjustment of the resection plane during laparoscopic subtotal pancreatectomy.
Case 3: A 69-year-old male with polycystic pancreas and suspected NET. Intraoperative EUS validated two lesions and clarified their anatomical relation to critical vessels, enabling a targeted, vessel-sparing Whipple procedure.
Case 4: A 77-year-old female with a glucagon-producing NET not identifiable through inspection or palpation. EUS intraoperatively localized the lesion and delineated margins, ensuring oncological completeness and parenchymal preservation.
In all cases, the same endoscopist performed both diagnostic and intraoperative EUS. This strategy enhanced surgical precision, reduced operative ambiguity, and was seamlessly integrated into the surgical workflow. To our knowledge, this is the first reported case series of prospectively planned intraoperative EUS applied across diverse pancreatic tumors. This approach demonstrates a reproducible model for interdisciplinary collaboration between surgeons and endoscopists as well as real-time surgical decision-making in high-complexity settings.

References

Illustrative material
Image 1 – Preoperative EUS showing a 5 mm solid lesion (Case 1).
Image 2 – Intraoperative EUS of cystic lesions with mural nodule (Case 2).
Image 3 – Postoperative EUS of surgical specimen confirming lesion (Case 3).
Image 4 – OR setup adapted for intraoperative EUS integration (Case 4).

Introduction

Primary sclerosing cholangitis (PSC) is known to present characteristic cholangiographic findings; however, detailed observations using peroral cholangioscopy (POCS) have rarely been reported. We previously reported that POCS findings in PSC can be classified into three types: active (inflammatory), chronic (scarring), and tumorous (tumor-like). These findings may aid in the differential diagnosis of PSC and may be useful in predicting prognosis.

Aims & Methods

We aimed to analyze POCS findings in PSC in detail based on this classification and to clarify their characteristics by evaluating the frequency of each finding, their temporal changes, and comparisons with other biliary diseases.
We retrospectively reviewed 22 patients with PSC who underwent POCS between February 2018 and February 2023. For comparison, we included 19 cases of hepatolithiasis, 25 cases of cholangiocarcinoma, and 3 cases of IgG4-related sclerosing cholangitis (IgG4-SC). Twelve POCS findings were categorized into three types: active (mucosal erythema, ulcers, fibrous white exudates, irregular surface), chronic (longitudinal scarring, annular scarring, pseudodiverticula, stenosis), and tumorous (dilated vessels, tortuous vessels, friability, mass formation). In addition, we included “punched-out lesion (POL)” as an original finding. Each finding was graded on a 5-point scale (0–4) based on the extent or number of lesions, and scores were calculated for each type. We conducted three analyses: (1) correlation between cholangiographic and POCS findings in PSC, (2) temporal changes in POCS findings in PSC, and (3) comparison of POCS findings between PSC and other biliary diseases.

Results

In the first analysis, annular scarring (100%), stenosis (89%), POL (89%), and longitudinal scarring (86%) were frequently observed in PSC. Annular scarring was identified in all cases with a shaggy appearance on cholangiography, and stenosis were present in all ducts with band-like stricture. In ducts showing diverticulum-like outpouchings, longitudinal and annular scarring, pseudodiverticula, and POL were consistently seen, whereas other findings were absent. In the second analysis, active and tumorous scores varied over time even within the same case, whereas chronic scores remained stable or showed a progressive increase. A negative correlation was observed between active and chronic scores (p-value <0.001, r =-0.702). In the third analysis, chronic findings and POL were significantly more common in PSC compared to other diseases (p-value <0.001). Pseudodiverticula were seen exclusively in PSC, while dilated and tortuous vessels and friability were significantly more frequent in cholangiocarcinoma and IgG4-SC (p-value <0.001).

Conclusion

These findings suggest that the characteristic cholangiographic findings of PSC are mainly formed by chronic scarring. Diverticulum-like outpouchings reflect only fibrotic changes. Furthermore, the coexistence of inflammation and fibrosis, along with the time-dependent progression of fibrosis, is a unique feature of PSC, although active inflammation may obscure chronic findings. Finally, longitudinal scarring and POL were particularly prominent in PSC, and pseudodiverticula were highly specific to this disease, suggesting their usefulness in differential diagnosis. In conclusion, chronic findings on POCS are characteristic of PSC and may serve as a helpful tool in its diagnosis and differentiation from other biliary diseases.

References

T Fujisawa, M Ushio, S Takahashi, et al., Role of Peroral Cholangioscopy in the Diagnosis of Primary Sclerosing Cholangitis. Diagnostics (Basel), 2020. 10(5).
T Itoi, T Kamisawa, Y Igarashi, et al., The role of peroral video cholangioscopy in patients with IgG4-related sclerosing cholangitis. J Gastroenterol, 2013. 48(4): p. 504-14.
T H Karlsen, T Folseraas, D Thorburn, et al., Primary sclerosing cholangitis - a comprehensive review. J Hepatol, 2017. 67(6): p. 1298-1323.
T Nakazawa, K Notohara, S Tazuma, et al., The 2016 diagnostic criteria for primary sclerosing cholangitis. J Gastroenterol, 2017. 52(7): p. 838-844.
T Nakazawa, H Ohara, H Sano, et al., Cholangiography can discriminate sclerosing cholangitis with autoimmune pancreatitis from primary sclerosing cholangitis. Gastrointest Endosc, 2004. 60(6): p. 937-44.
H Isayama, S Tazuma, N Kokudo, et al., Clinical guidelines for primary sclerosing cholangitis 2017. J Gastroenterol, 2018. 53(9): p. 1006-1034.
W L Campbell, M S Peterson, M P Federle, et al., Using CT and cholangiography to diagnose biliary tract carcinoma complicating primary sclerosing cholangitis. AJR Am J Roentgenol, 2001. 177(5): p. 1095-100.