Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) is the best choice to treat choledocholithiasis and obstructive jaundice in pancreatic or biliary neoplasms. Endoscopic ultrasound (EUS) has shown the best diagnostic accuracy for detecting common bile duct (CBD) stones, also showing an essential role for correctly staging pancreatic and biliary neoplasms. EUS and ERCP have been considered historically as two separate procedures; however, during the last decade, a same-session execution has gained popularity. Towards this process, bilio-pancreatic endoscopy was born.

Aims & Methods

We aimed to evaluate the efficacy and safety of same-session EUS-ERCP (SSEE) in treating choledocolithiasis and distal malignant biliary strictures compared to two-session procedures (TSEE). We retrospectively studied all consecutive patients enrolled in a 2-year period (January 2021 and December 2023) undergoing EUS and ERCP to treat choledocolithiasis or obstructive jaundice for malignant distal CBD strictures at an Italian tertiary referral Centre. Patients were divided into two groups: “same session EUS and ERCP group” (SSEE) and “two sessions EUS and ERCP group” (TSEE). Procedural ERCP success, the onset of major adverse events (moderate-to-severe-post-ERCP acute pancreatitis [ASGE guidelines], moderate-to-severe early and/or delayed bleeding [ASGE guidelines], duodenal and/or biliary perforation [Stapfer classification]), and all variables conventionally associated with the procedure were compared between the two groups of therapeutic strategy.

Results

At the end of the study, 200 patients were included (M/F 103/97; mean age: 71 years). The main features of the patients are reported in Table 1. Hundred (50%) patients were treated by the SSEE approach, while the remaining 100 (50%) by the TSEE modality. No statistically significant difference between the two groups was recorded in terms of ERCP overall success (95% vs 99%; p=n.s.). When considering major adverse events, no significant difference was seen between the two groups (0% vs 1%; p=n.s.). Regarding procedural features, the total procedure time (EUS + ERCP) did not significantly differ between the two groups (71.40 min vs 75.05 min; p=n.s.). We did not record major complications (acute pancreatitis, acute cholangitis, acute cholecystitis) during the waiting time between EUS and ERCP (average of 4.03 days) in the TSEE group. By contrast, a mean 3-day gain in terms of hospitalization length was observed in the SSEE group.

Conclusion

Our single-centre experience shows that both SSEE and TSEE approaches are safe and effective in patients undergoing EUS plus ERCP. Delaying the execution of ERCP from EUS, with reduced and appropriate inter-procedural waiting times, proves to be safe and effective, especially in cases involving specific patient conditions (altered anatomy, need for anaesthesiologic assistance, major comorbidities etc.) or the pathology to be treated. Finally, the SSEE approach seems to be more cost-effective with a gain of 3-mean-day in terms of hospitalization length.

Introduction

A biliary stricture is a narrowing of intrahepatic and/or extrahepatic biliary system with upstream dilatation¹; 70-80% of biliary strictures are malignant¹ therefore histological diagnosis is necessary to distinguish benign from malignant causes and guide management. Strictures without confirmed histology are referred to unexplained biliary strictures². ESGE (European Society of Gastrointestinal Endoscopy) guidelines recommend an integrated diagnostic approach that combines multiple techniques to improve diagnostic accuracy. Endoscopic ultrasound(EUS) has demonstrated high sensitivity for evaluating biliary strictures and unexplained common bile duct (CBD) dilatation, due to its ability to provide high-resolution images of CBD walls and surrounding structures, so is the preferred diagnostic modality for both imaging and tissue acquisition(TA), even in absence of abnormal laboratory test.¹ The introduction of ancillary techniques, as DFI (Detective Flow Imaging), which enables the detection of low-velocity blood flow without the use of contrast media, represents a potential useful addition in the diagnostic algorythm³.

Aims & Methods

The aim of this single-centre retrospective study is to validate the role of EUS-DFI in characterizing unexplained biliary strictures and CBD dilatation. We included consecutive patients (pts) with unexplained biliary strictures/CBD dilatation who underwent biliopancreatic EUS between January 2024 and April 2025 at the Digestive Diseases Unit of Sant’Andrea University Hospital, Rome. During EUS, biliary stricture (lesions or thickening of CBD wall) were described as hypoechoic or isoechoic. DFI was performed to evaluate strictures: if microvascularization was observed, vascular pattern was classified as regular or irregular⁴. Results were compared with the final diagnosis, defined by histopathology and/or ≥6 months clinical follow-up as gold standard. TA was performed with EUS-FNB (fine needle biopsy) and/or ERCP(Endoscopic Retrograde Cholangiopancreatography) intraductal biopsies/brushing.

Results

Of 13 patients included, 8(61.5%) were male, median age 72 (range 56-86). All underwent Magnetic Resonance Imaging/Contrast-Enhanced Computed Tomography as first line imaging: 3(23%) had a perihilar stricture, 9(69%) a medio-distal, 1(8%) had “in toto” CBD thickening. Among the 13 strictures, EUS identified 10(76.9%) lesions, with a mean diameter of 17 mm (median 16 mm; range, 5–35 mm), and 3(23.1%) CBD wall thickening. Twelve (92%) strictures were hypoechoic, 1(8%) was isoechoic. EUS-TA was performed in all pts, revealing 7(54%) cases of malignancies, of whome 5 cholangiocarcinoma and 2 pancreatic ductal adenocarcinoma (PDAC), 3(23%) high-grade dysplasia, and 3(23%) fibroinflammatory disease on histopatological evaluation. All pts underwent DFI-EUS. Microvascularization was detected in 12 cases (92%), with an irregular pattern observed in 9 pts. Among these, 5 (55.6%) were diagnosed with cholangiocarcinoma, 1(11.1%) with PDAC infiltrating CBD, and 3(33.3%) with high-grade dysplasia. The 3 benign strictures demonstrated a homogeneous pattern. One case (8%), corresponding to a PDAC, appeared hypovascular on DFI.

Conclusion

In a small cohort of patients with unexplained or indeterminate biliary strictures, the novel DFI-EUS technique proved to be feasible for assessing microvascularization in CBD stenosis and revealed characteristic irregular patterns or hypovascularization in malignant lesions. Further prospective studies with a larger patient population are needed to confirm these preliminary findings.

References

1. Facciorusso, A. et al. Diagnostic work-up of bile duct strictures: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 57, 166–185 (2025).
2. Zhang, W., Chai, N., Wu, Q. & Linghu, E. The new criteria for differential diagnosis of indeterminate biliary stricture under super minimally invasive peroral cholangioscopy. Chin Med J (Engl) 137, 255–256 (2024).
3. Yamashita, Y. et al. A Novel Endoscopic Ultrasonography Imaging Technique for Depicting Microcirculation in Pancreatobiliary Lesions without the Need for Contrast-Enhancement: A Prospective Exploratory Study. Diagnostics 11, 2018 (2021).
4. Yamashita, Y. et al. Novel Technique of Endoscopic Ultrasonography for the Differential Diagnosis of Gallbladder Lesions and Intraductal Papillary Mucinous Neoplasms: A Single-Center Prospective Study. Diagnostics 13, 2132 (2023).

Introduction

EUS-guided choledochoduodenostomy using a lumen-apposing metal stent (EUS-CDSL) has been shown in randomized controlled trials (RCT) to be effective compared to endoscopic retrograde cholangiopancreatography (ERCP) in patients with advanced malignant distal biliary obstruction (MDBO). We aimed to further ascertain the safety of EUS-CDSL, which has been limited by inadequate trial sample sizes.

Aims & Methods

We undertook aggregate and individual patient data (IPD) meta-analyses following the PRISMA-IPD statement. A literature search was performed from January 2013 to November 2024 using OVID MEDLINE, EMBASE, Cochrane Library, and ISI Web of Science. Additional searches were performed for abstracts and the grey literature. RCTs comparing EUS-CDSL to ERCP were included. The primary outcome was the rate of procedure-related 14-day severe or fatal adverse events (AE). Secondary outcomes included technical success, 30-day AE, clinical success, stent dysfunction, and procedure time.

Results

A total of 2679 citations were screened with three RCTs included (519 patients). There was no difference in severe or fatal AEs between EUS-CDSL and ERCP (OR 0.64, 95% CI 0.22- 1.83 for IPD data and RR 0.76, 95% CI 0.22, 1.77 for aggregate data). Technical success was greater for EUS-CDSL (OR 4.22, 95% CI 2.35,7.61 and RR 1.14, 95% CI 1.04, 1.25) with shorter procedural time (mean difference -10.50 minutes (95% CI -15.28, -5.73). No significant differences were noted in 30-day AEs, clinical success, and stent dysfunction.

Conclusion

Our aggregate and IPD meta-analyses demonstrate the safety of EUS-CDSL as a first-line alternative to ERCP in advanced MDBO. In addition, EUS-CDSL is technically superior in terms of success rate and procedure time.

Introduction

Eosinophilic Esophagitis (EoE) is a clinicopathological disease that requires an integrated assessment combining clinical, endoscopic, and histological findings. Despite this, treatment decisions often remain symptom based. A treat-to-target strategy has recently been proposed to guide EoE management.

Aims & Methods

Retrospective single-center study of EoE patients followed between March 2012 and January 2024, with ≥12 months of follow-up. Clinical, endoscopic, histological data, and complications were assessed using the I-SEE score.

Results

A total of 82 patients with EoE were evaluated [75.6% (n=62) male, mean age 29 ± 13 years], with 37.8% (n=31) diagnosed during childhood. The most frequent symptom was food impaction (74.4%), and atypical symptoms were more common in pediatric patients (p=0.014). At baseline, 55.1% (n=43) presented with a fibrostenotic phenotype, more frequently in adults (p=0.012), and 32.9% (n=27) had moderate-to-severe disease based on the I-SEE score.
During follow-up, 56.1% (n=46) developed complications, most commonly food impaction requiring endoscopy. The presence of a fibrostenotic phenotype on initial endoscopy was a predictor of complications (OR 3.122; 95% CI 1.210–8.055; p=0.019). Both fibrostenotic phenotype (p=0.018) and moderate-to-severe I-SEE scores (p=0.004) were associated with increased need for therapeutic switching.
At 12 months, 50.0% (n=41) were asymptomatic; however, only 12.2% (n=10) had endoscopic healing and 9.8% (n=8) histologic remission. Throughout the study period, the rates of endoscopic and histologic healing remained below 25%.

Conclusion

The authors highlight the clinical dissociation of inflammatory activity and emphasize the importance of endoscopic and histologic healing to prevent disease progression.

References

Dellon, Evan S., et al. "A clinical severity index for eosinophilic esophagitis: development, consensus, and future directions." Journal of Allergy and Clinical Immunology 150.1 (2022): 33-47.

Introduction

Irritable bowel syndrome (IBS) pathophysiology is multifactorial, with fermentable, oligo, di- and mono-saccharides and polyols (FODMAP) playing a role in symptom induction, presumably through osmotic effects and rapid colonic fermentation. While dietary studies assessed effects on symptoms, few have investigated the direct impact on colonic motility.

Aims & Methods

Using high-resolution colonic manometry (HRCM), we examined the effects of intracolonic fructose, fructans (fructo-oligosaccharides), or mannitol infusion on colonic motility in healthy volunteers (HV).
A double-blind three-way crossover study was conducted in 15 HVs, with a ≥ 2-week wash-out period between visits. After three days of a low FODMAP and low fiber diet, subjects came fasted to the hospital's endoscopy unit. They received a 250 mL water enema before advancing a 36-sensor solid state HRCM catheter with perfusion lumen into the ascending colon via colonoscopy under conscious sedation. After a 1 h recovery period, colonic pressures were recorded 1 h in the fasted state, for 20 min during infusion of FODMAP in the ascending colon (200 mL 290 mOsm/kg fructose, fructans, or mannitol), 2 h post-infusion, and 1 h postprandially after a standardized low-calorie meal. Colonic motor patterns were manually identified and compared between the three FODMAPs, with long ones ≥12 cm and high amplitude ones with at least 3 sensors ≥100 mmHg. Gastrointestinal symptoms were recorded every 15 minutes during the 4.5 h measurement. Results are presented as median with minimum and maximum ranges.

Results

Fifteen HV, 40% male (mean age 32 years (range 19-64 y), mean BMI 22.6 kg/m² (range 19.6-33.1)), completed the three study visits. Post FODMAP infusion, a significant difference in long anterograde patterns (p=0.04) was detected (Table). Postprandially, long synchronous (p=0.001) and long anterograde (LA) (p=0.0008) were more frequently observed with fructans, while mannitol tended to induce long retrograde patterns (p=0.07). Many of the long anterograde patterns were pan-colonic interrupted pressurizations (IP; previously described as related to gas transit; Leibbrandt J Clin Med 2023), and these were significantly more frequent after fructans infusion (p=0.004). High-amplitude retrograde-propagating contractions occurred 36 times in five HV: 50% after mannitol, 25% after fructans, and 25% after fructose infusion. There was no significant difference in gastrointestinal symptoms between the three FODMAPs, although flatulence and abdominal cramps were slightly increased after infusion of fructans.

Conclusion

Fructans and mannitol alter colonic motility patterns in distinct ways. Upon fructan infusion, there is a higher frequency of anterograde and synchronous activity, including interrupted pressurizations, which are suggested to be linked to gas transit. However, the frequency of these motor patterns was not altered by mannitol. These responses to different FODMAPs may contribute to symptom generation in IBS.

References

Van den Houte et al. Gastroenterology 2024
Leibbrandt J et al. Clin Med 2023

Introduction

Dietary changes are common in individuals with inflammatory bowel disease (IBD) to manage symptoms and avoid perceived triggers. However, such adaptations may predispose patients, especially adolescents and young adults, to eating disorders (ED) and avoidant/restrictive food intake disorders (ARFID).

Aims & Methods

This cross-sectional study aimed to assess the prevalence of ED and ARFID in young adults with paediatric-onset IBD, identify associated risk factors, and examine the relationship between ED, ARFID and the risk of malnutrition. Patients previously diagnosed with IBD at <18 years of age and currently followed at two adult IBD academic centers were consecutively enrolled. Screening for ED, ARFID and malnutrition was performed. ARFID risk was assessed using the Nine Item ARFID Screen (NIAS), which evaluates picky eating, low appetite, and food-related fear, with scores >23 were indicating probable ARFID. ED risk was evaluated using the Eating Attitudes Test (EAT-26), with scores ≥20 considered positive. Malnutrition risk was assessed using the Patient-Generated Subjective Global Assessment (PG-SGA), with scores >=6 indicating malnutrition¹​

Results

A total of 144 patients were included (median age 24 years [range: 21–28]; 54.2% female), with 50.7% diagnosed with Crohn’s disease (CD). History of enteral nutrition during childhood was reported in 40.3% of patients, predominantly among those with CD (64.4%). At the time of evaluation, one-third (34.7%) of the cohort had active disease, and the median BMI was 21.8 (IQR 20.1–24.2).
ARFID risk was observed in 16.7% of patients, with food-related fear being the most prevalent domain (13.2%) with no significant association with the disease activity (37.5% vs 34.2%; p=0.46). Based on EAT-26 scores, 11.8% screened positive for ED. The PG-SGA scores correlated significantly with the NIAS scores (rho=0.56, p<0.001) but not with EAT-26 (p=0.26). Malnutrition (PG-SGA ≥6) was observed in 15.3% of the cohort and it was significantly associated with ARFID risk (p<0.001). Prior exposure to enteral nutrition was not associated with increased ARFID risk (p=0.54), but was significantly associated with a reduced risk of ED (p=0.008).

Conclusion

Young adults with pediatric-onset IBD are at risk of ARFID, especially driven by food-related fears, and, to a lesser extent, of ED. Prior exposure to enteral nutrition was not associated with increased ARFID risk, but it was associated with a reduced risk of ED, supporting its safe use in pediatric IBD management. Routine assessment for eating disorders and malnutrition risk should be standard practice in IBD care for young adults

References

1. Gabrielson DK, Scaffidi D, Leung E, et al. Use of an abridged scored Patient-Generated Subjective Global Assessment (abPG-SGA) as a nutritional screening tool for cancer patients in an outpatient setting. Nutr Cancer. 2013;65(2):234-239. doi:10.1080/01635581.2013.755554