Introduction

Inadequate bowel preparation (BP) is associated with lower adenoma and polyp detection rates (ADR and PDR). Although it is logically assumed that improving BP would result in higher ADR and PDR, recent studies have challenged this assumption and shown that ADR and PDR decreased at the highest levels of BP¹⁾. However, these studies were limited by retrospectively collected data and lack of adequate adjustment of confounders related to ADR and PDR including colonoscopy withdrawal time.

Aims & Methods

This cross-sectional study aimed to evaluate the effects of BP quality using the Boston Bowel Preparation Scale (BBPS) and withdrawal time on ADR and PDR in colonoscopies with adequate preparation. This study was based on prospectively collected data from patients who underwent screening or surveillance colonoscopy from March to December 2019 and had adequate BP (BBPS >6). All patients received low-volume polyethylene glycol solution with ascorbate on the day of examination. Clinical characteristics and comorbidity data related to adenoma incidence and BP were collected using a questionnaire. Endoscopic findings associated with PDR and ADR, including BPPS and withdrawal time, were assessed by eight experienced (>1000 procedures) gastroenterologists. Withdrawal time was defined as the time from cecal inspection to exit from the anal verge, excluding the time for biopsy and cold snare polypectomy. All polyps were evaluated histopathologically. Factors associated with PDR and ADR were determined using logistic regression analysis.

Results

A total of 1007 patients with adequate BP were included. The PDR and ADR were 55% and 47% respectively. The BBPS-9 rate, PDR and ADR did not differ between the endoscopists. ADR (52% vs 41%, P<0.05) and PDR (60% vs 47%, P<0.05) were higher in the good BP group (BBPS 6,7,8) than in the highest BP group (BBPS 9). Median withdrawal time was shorter in the highest BP group than in the good BP group (7 min vs 8 min, P<0.01). There was no significant difference in indications for colonoscopy between the good and highest BP groups. Patients with polyps and adenomas were older, more likely to be male, and had longer colonoscopy withdrawal time than those without polyps and adenomas. However, in multivariate analysis, longer withdrawal time, but not BBPS, was significantly associated with both ADR (OR 1.12; 95% CI 1.07–1.18; P<0.001) and PDR (OR 1.13; 95% CI 1.07–1.18; P<0.001).

Conclusion

ADR and PDR decreased at the highest BP levels. However, longer withdrawal time, not the highest BBPS, was significantly associated with ADR and PDR in the adequate BP group. The decrease in ADR and PDR in cases with the highest BP may be the result of shorter withdrawal times. Endoscopists should be careful not to miss polyps due to overconfidence and short observation time when the BP is perfect.

References

1) Calderwood et al. Gastrointestinal Endoscopy 2015;81:691-699

Introduction

According to the latest clinical practice guidelines, the empirical antimicrobial therapy used for managmente of patients with acute cholangitis should be established according to its level of severity. However, this recommendation have been highly questioned in those settings where the prevalence of broad spectrum beta-lactamase (ESBL) producing E.coli or Klebsiella exceeds 10-20%, and some experts recommend starting with a broader coverage in a systematic way.

Aims & Methods

To evaluate the prevalence of multidrug-resistant cholangitis in our hospital setting, identify possible predictors and antibiotic adequacy.
We made a retrospective analysis of 331 patients diagnosed with acute cholangitis (gathering demographic, clinical, analytical and microbiological data) admitted to the Hospital del Mar during the period from 2018 to 2021.

Results

After assessing the baseline characteristics of theses sample, we obtained a mean age of 78 years, and 53% male. Blood cultures were extracted in 92% of the patients, of which 49% were positive (149 patients) and of these, 12% had multiresistant germs (19 patients, with 17 cases positive for BLEE). The most frequent empirical regimens were amoxicillin-clavulanic acid (112 cases) and cephalosporins with metronidazole (120 cases) with 94.8% and 96.1% of therapeutic adequacy, respectively. The bacteria identified were mainly: E.coli (88%), Enterobacter spp (16%) and Klebsiella spp (21%). Previous colonization by multidrug-resistant germs (3.9%) and institutionalized patients (5.14%) were the only variables related to the presence of cholangitis due to multidrug-resistant germs, but in the multivariate analysis only colonization was a predictor factor (OR 6.69, CI 1.16-38.35). No analytical or hemodynamic variables were found to be associated to bacteremia due to multidrug-resistant germs. Otherwise, bacteremia due to multidrug-resistant germs didn't correlate with a higher mortality.

Conclusion

The prevalence of multidrug-resistant cholangitis in our setting is considerable. However, high antibiotic adequacy is achieved with amoxicillin-clavulanic acid or third generation cephalosporins in most cases. In patients with history of infection or previous colonization by conflicting germs, a broad-spectrum antibiotic coverage including multidrug-resistant germs should be considered empirically.

Introduction

Although there is a childhood vaccination program against hepatitis B virus (HBV) in Greece, vaccination rates are thought to be suboptimal both in general population and in inflammatory bowel disease (IBD) patients^1,2. Wide use of new immunosuppressant and biologic therapy could lead to an oppurtunistic infection. As it is recommended by European Crohn's and Colitis Organisation (ECCO) for prevention of HBV infection, patients should be serologically screened at baseline, before and during an immunosuppressive therapy³ and be appropriately vaccinated. Vaccination is until now the most effective way in order to protect from HBV offering longtime protection. Lower successful immunization rates are seen after induction of immunosuppressant therapy carrying a higher risk of a current HBV infection and complications.There are limited epidemiological data about successful immunization, among Greek patients with inflammatory bowel disease, prior to immunosuppressant therapy initiation¹.

Aims & Methods

The aim was to detect the vaccination rate against HBV among IBD patients who are going to be treated with immunosuppressant therapy. Retrospectively collected data from medical records of IBD patients in a single referral IBD center between 2017 and 2023 were analyzed. Inclusion criteria were IBD patients prior to immunosuppressant therapy initiation with no natural immunity to HBV, absence of hepatitis B surface antigen (HBsAg), absence of isolated hepatitis B core antibody (anti-HBc) and any status of hepatitis B surface antibody (anti-HBs).

Results

In total 126 patients were included in the study with average age 46 years old (+/- 28 years old). 42.86% (54/126) of them were women and 57.14% (72/126) were men. 52.38% (66/126) had been diagnosed with Crohn's disease and 47.61% (60/126) with ulcerative colitis. In total 40,48% (51/126) had positive anti-HBs, because of successful immunization against HBV and 59.52% (75/126) were seronegative.

Conclusion

Our study confirms inadequate immunization results against hepatitis B among IBD patients in Greece. Intensive care should be given in vaccination protocols and serology testing especially in IBD patients that are going to start immunosuppressive agents. Primary care and IBD specialist should be well informed about serology testing and appropriate vaccination against hepatitis B, carefully advise and strongly recommend vaccination in IBD patients.

References

1. Fousekis FS, Katsanos KH, Theopistos VI, Baltayiannis G, Kosmidou M, Glantzounis G, Christou L, Tsianos EV, Christodoulou DK. Hepatobiliary and pancreatic manifestations in inflammatory bowel diseases: a referral center study. BMC Gastroenterol. 2019 Apr 3;19(1):48. doi: 10.1186/s12876-019-0967-3. PMID: 30943899; PMCID: PMC644630
2. Tsiligianni I, Bouloukaki I, Papazisis G, Paganas A, Chatzimanolis E, Kalatharas M, Platakis I, Tirodimos I, Dardavesis T, Tsimtsiou Z. Vaccination coverage and predictors of influenza, pneumococcal, herpes zoster, tetanus, measles, and hepatitis B vaccine uptake among adults in Greece. Public Health. 2023 Oct 9;224:195-202. doi: 10.1016/j.puhe.2023.09.002. Epub ahead of print. PMID: 37820537.
3. T Kucharzik, P Ellul, T Greuter, J F Rahier, B Verstockt, C Abreu, A Albuquerque, M Allocca, M Esteve, F A Farraye, H Gordon, K Karmiris, U Kopylov, J Kirchgesner, E MacMahon, F Magro, C Maaser, L de Ridder, C Taxonera, M Toruner, L Tremblay, M Scharl, N Viget, Y Zabana, S Vavricka, on behalf of the European Crohn’s and Colitis Organisation [ECCO], ECCO Guidelines on the Prevention, Diagnosis, and Management of Infections in Inflammatory Bowel Disease, Journal of Crohn's and Colitis, Volume 15, Issue 6, June 2021, Pages 879–913

Introduction

Type 2 is a less frequent and known form compared to type 1 autoimmune pancreatitis (AIP). Despite considered as a benign form, only few studies with a short follow-up have been published on type 2 AIP.

Aims & Methods

Patients with definitive or probable diagnosis of type 2 AIP by International Consensus Diagnostic Criteria (ICDC) present in our prospectively maintained database since 1995 were identified. All patients were contacted and clinically evaluated during the year 2022. Uncontactable patients and patients refusing clinical evaluation were considered as lost at follow-up. Clinical, radiological, serological, and pathological reports were evaluated.

Results

Eighty-eight patient out of 420 AIP patients present in the database (21%) were diagnosed as type 2 AIP (55 males, 33 females, mean age at clinical onset 33.5±13.5 years, range 16-71). According to the ICDC, 21 patients (23.8%) had a definitive and 67 a probable diagnosis of type 2 AIP. Mean follow-up time was 9.2±7.1 years (range 1-27 years). No differences were observed comparing patients with definitive and probable type 2 AIP diagnosis. Concomitant IBD was reported in 77 patients (87.5%), mostly diagnosed before or at the same time of type 2 AIP. Nine patients were drop out (10.2%). Survival curve evaluated a probability of ralapse of 27% at 5 years and 29% at 10 years. Risk of endocrine or severe exocrine insufficiency were relatively low, 5% and 25% respectively. Four extra-pancreatic malignancies (5%) were diagnosed (1 renal, 1 breast, 1 rectum and 1 prostate cancer), none pancreatic. 1 patient died for car accident.

Conclusion

Patients affected by type 2 AIP have a benign long-term clinical outcome. Mortality rate was low, as well as extra-pancreatic and pancreatic malignancies.

Introduction

The mainstay of treatment of Zenker’s diverticulum is cricopharyngeal myotomy. Although flexible endoscopic septotomy is widely implemented, complete myotomy is difficult to assess resulting in recurrence rates of 11%. On the other hand, ZD peroral endoscopic myotomy allows complete myotomy visual confirmation, at the expense of procedure length and complexity. To overcome these limitations, a hybrid technique that allies FES simplicity and fastness to zPOEM efficacy is proposed: 1-septum isolation with overtube; 2-standard FES until middle of the diverticulum; 3-muscular septum isolation by zPOEM until the base of the diverticulum; 4-complete myotomy; 5-residual mucosal flaps section; 6-mucosotomy closure with TTS clips. We aim to demonstrate the feasibility, effectiveness and safety of the hybrid zPOEM technique for the treatment of ZD.

Aims & Methods

A retrospective analysis including patients with ZD treated by hybrid zPOEM procedure from April 2021 to February 2023 was made. Technical success, early clinical success (dysphagia score ≤ 1), adverse events and recurrence rates were evaluated.

Results

11 patients (male 54.5%, mean age 72.9 years) underwent hybrid zPOEM procedure for treatment of ZD (mean size 23.18mm, range 15-30mm). The procedure was technically successful in all patients, with a mean procedure time of 21.6 minutes. Early clinical success was achieved in all patients, although 1 patient maintained occasional regurgitation due to incomplete mucosal flaps section. Mean symptoms scores improved from baseline for dysphagia (1.5 vs 0), regurgitation (1.5 vs 0.1), halitosis (0.5 vs 0), cough (0.5 vs 0) and hoarseness (0.3 vs 0). During a mean follow-up time of 10 months, no recurrence was recorded. No intra- or post-procedure AE were recorded.

Conclusion

Hybrid zPOEM technique is a fast, safe and effective procedure, where, by combining classic FES and zPOEM, one can have the best of both techniques. This procedure should be considered as a first-line therapeutic option in third-space-endoscopy experienced centers.

References

Zhang LY, Nieto J, Ngamruengphong S, Repici A, Khashab MA. Zenker’s diverticulum: advancing beyond the tunnel. VideoGIE. 2021;6(12):562–7
Lupu A, Lafeuille P, Yzet C, Benech N, Jacques J, Rivory J, et al. Hybrid peroral endoscopic myotomy for large Zenker’s diverticulum. Endoscopy. 2022;54:E862–3.
Krishnan A, Ichkhanian Y, Runge TM, Khashab MA. Hybrid endoscopic approach for submucosal tunneling septum division for Zenker s diverticulum. Endoscopy. 2020;52(12):E457–8.

Introduction

The molecular pathways for the development of ulcerative colitis (UC) are unclear. The purpose of the work is to study the molecular interactions of the apoptotic pathway in patients with UC.

Aims & Methods

The study was prospective comparative cohort with parallel design and included 65 patients (range from 22 to 35 years, 24 men and 41 women) with left-sided UC, mild and moderate activity (Truelove - Witts’ criteria, Mayo score). The induction of UC remission assumed the acceptance of mesalazine 3 to 4 g/day p.o. and rectally 1 to 2 g/day, the duration of therapy was 4.6 years. The control group
included 30 healthy individuals. The separation of individual proteins of colon mucosa was based on technologies of IEF, SDS-PAGE, 2DPAGE, by standard sets (MB-HIC C8 Kit, MB-IMAC Cu, MB-Wax Kit, «Bruker», USA). Automated mass spectrometry imaging was performed by matrix-assisted laser desorption-ionization timeof-flight mass spectrometry (MALDI-TOF-MS/MS, Ultraflex II, «Bruker», USA). The partially identified sequences were then submitted to “BLAST protein-protein” and screened against the Homo sapiens Swissprot database to check if this identification matched the MASCOT-identification (Matrix Science, UK). The data of the molecular interactions and functional features of proteins were received with STRING 10.0 database. Based on the data of standard methods of identification of UC and molecular phenotyping of colon mucosa we conducted new prognostic markers, molecular pathways of UC and diagnostic tests in patients with UC. Statistical analysis of the survey data was performed using the software “Statistica 12.0” (Statsoft).

Results

Bioinformatics analysis revealed the presence of molecules that are the participants in the universal pathways of UC in the active stage, and the molecular interactions involved. We identified following functional groups of peptides and proteins in molecular patterns of bioptates of colon mucosa in UC patients: peptides and proteins regulating the barrier function of colon mucosa; proteins-participants of specific metabolism in epitheliocytes and endocrinocytes; proteins of the fibrosis in colon mucosa; proteins regulating cell cycle, oncogenesis, proteolysis in cell, hormones processing, angiogenesis, coagulation factors; proteins of free radical oxidation and antioxidant system; proteins regulating the receptor activity of epitheliocytes and immune cells; structural proteins of colon mucosa; transcription and translation factors regulating the activity of cell nucleus, regulators of protein folding; transport proteins; proteins-enzyms of detoxification. Significant decrease of the PPARγ expression promotes the activation of STAT and AP-1 signaling pathways, which promotes an increase in the synthesis of IL-2,6,8,12, TNFα, matrix metalloproteinases, the activity of immune and inflamation processes in colon mucosa. A significant increase in the NF-kB expression in colon mucosa is associated with the activation of TNFα and IL-1, which promotes the increase of immune processes in colon mucosa. The molecular interactions of β-defensin-1: the reduction of the β-defensin-1 expression in cells of colon mucosa is accompanied by increased expression of CCR6, which promotes the formation of inflammatory infiltrates in colon submucosa in UC.

Conclusion

Identification of potential new molecular markers for UC development may provide opportunities for the development of diagnostic tests to evaluate the disease.