Introduction

Acute esophageal variceal bleeding (EVB) typically requires initial treatment involving pharmacotherapy and endoscopy, particularly endoscopic variceal ligation (EVL). In cases of rebleeding, transjugular intrahepatic portosystemic shunt (TIPS) is recommended, but in regions with limited TIPS access, repeated endoscopic therapy is common. This study evaluates the outcomes of EVL in managing rebleeding and mortality in resource-constrained settings.

Aims & Methods

Patients experiencing acute EVB and undergoing EVL were followed for up to five years or until death. Treatment involved vasoactive drugs and EVL until variceal eradication was achieved. Primary endpoints included bleeding control effectiveness and the need for a second EVL session to manage rebleeding. Rebleeding and mortality rates at 6 weeks and 5 years were analyzed. Logistic regression analysis identified risk factors associated with rebleeding and mortality.

Results

Among 118 patients with acute EVB undergoing EVL, no treatment failures occurred within five days. Eighty-three percent were successfully controlled with one EVL session, while 17% required at least two sessions for recurrent bleeding. In the rebleeding group, no patients rebled within five days after the first EVL, but 75% rebled within 6 weeks. Second EVL was performed for these patients, with a failure rate of 25%. Recurrent EVBs were ultimately controlled by other endoscopic therapy. There was no significant difference in 6-week mortality between rebleeding (15%) and non-rebleeding (18%) groups (p=0.72). Factors associated with 6-week mortality included age, hepatocellular carcinoma, post-bleeding beta-blocker use, creatinine, bilirubin, albumin, Child-Pugh class, and MELD score (Table). Beta-blocker use was associated with preventing recurrent EVB within six months (OR 0.053, 95% CI: 0.004-0.687, p = 0.025). Over five years, the rebleeding group showed a higher mortality trend (90%) compared to the non-rebleeding group (68.8%), though not statistically significant (p=0.06).

Conclusion

In resource-limited settings, multiple attempts of EVL demonstrate success in controlling rebleeding. Long-term trends indicate higher mortality in rebleeding cases, although not statistically significant.

Disclosure

The authors declare that they have no conflict of interest.

Introduction

The prevalence of musculoskeletal disorders (MSD) among gastroenterologists is estimated between 39 to 89%. Factors associated with MSDs among endoscopists include a high number of procedures (over 20/week), prolonged procedure times (over 16 hours/week), the age of the endoscopist (> 40 years vs ≤ 40 years), and female sex.
This study aimed to evaluate the prevalence of MSD among French gastroenterologists and identify risk factors of MSD

Aims & Methods

A computerized, anonymized questionnaire was e-mailed to all members of French society of endoscopy (SFED) over a one-month period. Demographic data were collected, as well as the level of endoscopic activity performed, the quantity and volume of endoscopies performed per week, the presence of pain associated with the practice of endoscopy, and an assessment of stress.

Results

485 gastroenterologists responded to the questionnaires, the majority were male (55%), with a median age of 48 years (IQR 37–60), and 45.6% practiced endoscopy for more than 20 years. 74.3% of respondents worked full-time, mostly in private practice (47% in private practice, 13% in mixed public-private practice). Endoscopy was performed for a median of 15 hours per week (IQR 10–18.8), with 24 procedures per week (IQR 15–30).
76.3% of participants had already experienced joint and/or musculoskeletal pain related to work. Pain complaints mainly concerned the lower back (55%), shoulders (36% left, 37% right%), neck (50%), and wrists (30% both side). More than half of the participants (55.9%) reported that the pain persisted after procedures, with 17.8% experiencing nocturnal pain and about a quarter reporting pain lasting more than 3 months.
The impact of MSD on workload was evaluated. 5.1% of the gastroenterologists reported loss of efficiency, 3,8% adapted their job, 2.4% decreased their activity, and 2.1% had work stoppage. 35% declared to have management of their MSD (28.1% painkiller, 23.2% reeducation, 3.5% surgery). To reduce discomfort, 74.7% of respondents reported using an adjustable-height examination table, and half adjusted the height and distance of the screen.
In multivariate analysis, factors associated with MSD were, femal sexe (OR 1.85 (1.15-3.01) p = 0.012, number of endoscopy (OR 1.05 (1.01-1.11) p=0.03, activity > 20 years (OR 2.42 (0.89, 6.47) p=0.079.) The risk of MSD was higher after 16.5 hours of endoscopy/ week (Se 35%, Sp 83%).

Conclusion

Musculoskeletal pain among French gastroenterologists is common and concerning. Therefore, it is essential to develop preventive programs to support their health and ensure the quality and safety of care.

Introduction

​​​​​PSC is chronic infammatory disease of bile ducts leading to strictures of bile duct and eventually to liver cirrhosis. Chronic inflammation is associated with markedly increased risk of cholangiocancer (CCA). In addition, gall bladder abnormalities are common in patients with PSC¹ such as cholecystitis, gallstones, polys and gallbladder carcinoma (GBCA). Increased fasting gallbladder volume has been reported with normal gallbladder emptying². Due to the increased risk of GBCA³ cholecystectomy is recommended in PSC with gallbladder polyps ≥8 mm and smaller polyps growing⁴. However, cholecystectomy has been associated with impaired PSC outcome. A study consisting of 11 PSC patients with cholecystectomy suggested protective role of gallbladder based on MRCP changes and elevated AST levels in patients with cholecystectomy. No significant difference in serum bile acids was observed in patients with or w/o cholecystectomy⁵. Another small study including five PSC patients with cholecystectomy showed that cholecystectomy was associated with worse Mayo scores and an elevated FIB4⁶. More than 50% of PSC have enlarged gallbladder which is suspected to be caused by hyperpressure in the biliary tract⁵. Cholecystectomy may thus eliminate this reserve function and lead to progression of bile duct strictures.

Aims & Methods

To evaluate the impact of cholecystectomy on liver enzyme levels, biliary bile acid composition, bile duct disease progression, and overall outcomes in a large PSC patient cohort, we analyzed data from 1,009 individuals enrolled in the prospective Helsinki PSC registry. Of these, 114 patients (11.3%) had undergone cholecystectomy—34 prior to and 80 following the PSC diagnosis. Patients with gallbladder cancer were excluded. Clinical and laboratory parameters were collected, along with data on disease progression based on sequential ERC examinations scored by the Helsinki ERC score⁷. Additionally, bile composition was analyzed in a subgroup of 157 patients receiving UDCA therapy, 32 of whom had undergone cholecystectomy.

Results

Demographics, liver function tests, and outcomes stratified by cholecystectomy, are presented in the table. We found no differences between the three groups (no cholecystectomy, cholecystectomy done prior or after PSC dg) regarding the progression of bile duct disease or its severity, liver function tests, development of biliary dysplasia or need for dilatation, Mayo- and MELD-scores. The cumulative incidence of the composite end point (= transplantation, liver related death, HCC or CCA) did not differ between groups. The molar-% of phospholipids were lower and cholic acid and deoxycholic acid (mg) elevated in bile in patients with cholecystectomy, whereas no differences were found in UDCA content.

Conclusion

In this large study investigating the impact of cholecystectomy on PSC outcomes, we found no effect on liver enzyme levels, prognostic indices, bile duct disease progression, or overall prognosis, regardless of whether the procedure was performed before or after the PSC diagnosis.

References

1. Said K, eta al. Journal of Hepatology 2008; 48:598–605
2. Said K, et al. World J Gastroenterol 2009; 15: 3498-3503
3. van Erp LW, et al. Liver Int 2020; 40:382–92.
4. Chazouilleres O et al. EASL Clinical Practice Guidelines on sclerosing cholangitis. J Hepatol 2022; 77:761–806
5. Cazzagon N, et al. JHEP Reports 2023. https://doi.org/10.1016/j.jhepr.2022.100649
6. Miyake N, et al. Cureus 17(3): e80184. DOI 10.7759/cureus.80184
7. Boyd S, et al. Endoscopy. 2016;48:432-9.

Introduction

Gender diversity in scientific authorship is a progress indicator in various medical fields, including gastrointestinal (GI) endoscopy. The representation of women in academia reflects broader changes in professional roles and leadership. This study aims at analyzing trends in gender representation among authors of randomised controlled trials (RCTs) in GI endoscopy from the 1960s to the present, providing insights into the progression of gender equity in academic gastroenterology.

Aims & Methods

A PubMed search using the terms "digestive endoscopy" and "gastrointestinal endoscopy" was conducted on April 1st, 2024, yielding 5,944 studies filtered for RCTs. After excluding non-English articles, those unrelated to endoscopy, and studies without identifiable first authors, 4,357 RCTs were included. First and last authors' genders were identified using Genderize.io with ≥90% certainty. Descriptive and inferential statistics, including chi-squared tests, were used to analyze trends in gender representation over time.

Results

In total, there were 967 female first authors (21.7%), 3,415 male first authors (77.0%), and 57 unclassified first authors (1.3%). Out of 4173 last authors, 637 were female (15.3%), 3,203 were male (76.7%), and 333 were unclassified (8.0%) (p < 0.001). Female representation among last authors increased from 0% to approximately 20%, while first authors rose from 0% in the 1970s to about 30% by 2024 (p<0.05 for both trends). Multivariate regression confirmed that the increase in female first authorship was more significant compared to last authorship (p<0.001, R-square 0.90).Regarding specific topics, “non-IBD-related diagnostic lower GI endoscopy” showed the highest representation for female first authors at 25.5%, while “Obesity” and “Artificial Intelligence” had the lowest at 1.4% and 1.7%, respectively. For the last authorship, “non-IBD-related diagnostic lower GI endoscopy” led at 22.1%, followed by “Diagnostic upper GI endoscopy” at 14.0%. The lowest percentages among the last authors were “Obesity” at 1.4% and “Artificial Intelligence” at 0.6%. Statistical analysis revealed significant differences in gender representation across topics (p < 0.0001).Regional differences were noted, with female first authors more prevalent in Europe (36.2%) and Asia (31.0%), while female last authors were more common in Europe (34.2%) and North America (30.8%, p = 0.032), highlighting variations in gender dynamics within endoscopy research.

Conclusion

This study demonstrates a progressive increase in female representation in digestive endoscopy RCTs, particularly among first authors. However, gender disparities persist in senior roles, underscoring the need for continued efforts to support gender equity, especially in leadership positions within academic gastroenterology.

References

Liu CS et al. Am J Gastroenterol. 2024 Oct 1;119(10):2103-2106.
Genderize Data Roskilde, Denmark. Genderize.io (last access Nov 1st, 2024

Introduction

The Celiac Disease Symptom Diary Version 2.1 (CDSD v2.1) is a patient-reported outcome (PRO) measure designed to capture the severity of five celiac disease (CeD) symptoms (diarrhea, abdominal pain, bloating, nausea and tiredness) that have been identified as most relevant from the patient perspective.¹ The diary has a 24-hour recall period and symptoms are scored on a 5-point scale ranging from 0 = “none” to 4 = “very severe”. The present analysis aimed to confirm the reliability, validity and responsiveness of CDSD v2.1 average symptom severity scores and percentage of symptom-free days per week (%SFD) scores.

Aims & Methods

This psychometric analysis of the CDSD v2.1 was conducted using data from a double-blind, randomized, placebo-controlled, multicenter, phase 2 clinical study (NCT5353985)² assessing the efficacy and safety of zamaglutenase (TAK-062) in patients with moderate to severe CeD (N = 153). The CDSD v2.1 was electronically administered each evening throughout the study (6–8-week screening period and 24-week treatment period). Average gastrointestinal (GI) symptom severity and %SFD GI domain scores (for diarrhea, abdominal pain, bloating and nausea) were evaluated at 7-day intervals. Test-retest reliability was determined using intraclass correlation coefficients (ICCs). Construct validity was assessed via correlations between the CDSD v2.1 scores and the Gastrointestinal Symptom Rating Scale (GSRS) clusters, and by calculating mean CDSD v2.1 scores across known groups (defined using the Patient Global Impression of Severity [PGIS]). Responsiveness was evaluated by estimating mean CDSD v2.1 change scores by change in the PGIS and Patient Global Impression of Change (PGIC) between baseline and Week 24. Anchor-based methods using the PGIS and PGIC were also used to define meaningful within-patient change thresholds (MWPC). Cumulative distribution function (CDF) curves were generated to support estimation of MWPC.

Results

Test-retest reliability was adequate when measured from Weeks –4 to –2, with ICC values ranging from 0.66 to 0.72 for average GI symptom severity scores and 0.49 to 0.52 for %SFD GI domain scores based on estimates for the overall group and the stable subgroup (i.e., those with no change on the PGIS), respectively. Convergent validity was supported via moderate-to-strong correlations of respective GSRS clusters with average GI symptom severity (0.51–0.75) and %SFD GI domain (0.4–0.44) scores at Week 24. On average, patients who reported more severe symptoms on the PGIS had higher CDSD v2.1 composite scores than those who reported less severe symptoms (p < 0.001). Responsiveness correlations with the PGIS were adequate (> 0.37) and slightly lower with PGIC (0.32–0.37). CDSD v2.1 average GI symptom severity and %SFD GI domain change scores were correctly ordered, in terms of worsening/improvement, by the PGIS change groups and by the PGIC. Anchor levels selected to reflect meaningful improvement were 1-point improved PGIS and “little improved” PGIC. CDF curves at Week 24 were adequately separated among the anchor categories and their respective no-change groups.

Conclusion

The results from this study support the CDSD v2.1 as a reliable, valid and responsive measure and provide psychometric evidence for constructing clinical study endpoints based on change in average GI symptom severity or %SFD GI domain scores in patients with moderate to severe CeD.

References

1. Howard K, et al. Development of the Celiac Disease Symptom Diary version 2.1© (CDSD 2.1©) patient-reported outcome measure. Qual Life Res 2024;33:3275–82. doi: 10.1007/s11136-024-03799-6.
2. ClinicalTrials.gov. A study of TAK-062 in treatment of active celiac disease in participants attempting a gluten-free diet. Available from:https://clinicaltrials.gov/study/NCT05353985 (Accessed April 3, 2025).

Disclosure

SG, MJT, DL and MA are employees and shareholders of Takeda. NR and LM are employees of RTI Health Solutions, which received research funding from Takeda for conducting this study.

Introduction

The optimal bowel preparation for small bowel capsule endoscopy (SBCE) has not been standardized.

Aims & Methods

Compare the rate of complete examinations, quality of bowel preparation, diagnostic yield and tolerability, using three protocols for intestinal preparation for SBCE.
A prospective, multicentre, randomized clinical trial including consecutive patients submitted to SBCE was conducted. All patients were instructed to comply with a clear liquid diet and 12-hour fasting before the exam. After ingesting water and 100 mg of simethicone and swallowing the capsule, once it reached the small bowel, patients ingested a booster, randomized into one of three protocols: 1) 1 liter of polyethylene glycol (PEG), 2) 1 liter of PEG and ascorbic acid, 3) 1 liter of water. The patients’ bowel preparation was evaluated with SB-CLEAR. Each patient responded to a questionnaire about their tolerability.

Results

A total of 261 patients were included, 96 patients (36.8%) in protocol 1, 93 (35.6%) in protocol 2 and 72 (27.6%) in protocol 3. The rate of complete examinations, adequate bowel preparation and diagnostic yield were comparable among the groups (p=0.655, p=0.193 and p=0.589, respectively). The overall SB-CLEAR score was similar among the protocols (p=0.236). Although the preparation of the third tertile had a lower score using protocol 3 (protocol 1: 2.5±0.1 vs 2: 2.6±0.1 vs 3: 2.3±0.1, p=0.021), it did not compromise the mucosal visualization, maintaining a mean score above 2 and similar diagnostic yield among the protocols (p=0.850). The patients’ reported tolerability was higher in protocol 3 (protocol 1: 2.8±0.1 vs 2: 3.0±0.2 vs 3: 0.6±0.1, p<0.001).

Conclusion

Using 1 liter of water as a booster in SBCE was better tolerated and associated with comparable rates of complete examinations, adequate bowel preparation and diagnostic yield versus PEG with or without ascorbic acid.