Clinical Case Summary

A 24-year-old man presented with recurrent hematemesis and hematochezia for 8 months. He had a 3-year history of inherited thrombophilia, in which the celiac trunk and branches and portal vessels were extensively involved, and variceal bleeding, and portal cavernous transformation developed. Two sessions of endoscopic band ligation combined with sclerotherapy were performed to prevent re-bleeding, and he was hospitalized for third endoscopic therapy. During the procedure, spurting bleeding occurred when sclerosing agents were injected, and hemostasis was achieved utilizing titanium clip. At 30 hours after endoscopic treatment, he developed persistent pain in the left upper abdomen and left waist, accompanied by low-grade fever. Blood tests revealed an increased white blood cell count. Abdominal contrast-enhanced CT scanning showed large hypodense splenic areas. In conjunction with symptoms, and leukocytosis, splenic infarction was diagnosed. To understand cause of splenic infarction, CTA combined with 3D visualization was used, and revealed complete occlusion of splenic artery and several enlarged abnormal arteries traveling along gastric fundus to supply the spleen, which originated from the left gastric artery. Obviously, sclerosing agents were injected into the enlarged arterial branches of LGA, then caused splenic infarction. The patient received oral antibiotics and nonsteroidal anti-inflammatory drugs, and the symptoms gradually subsided.
Splenic infarction after cyanoacrylate injection in gastric varices has been documented¹, but the cause remains unclear. Although mucosal variceal vessels mostly originate from the deep submucosal veins, it may be difficult to distinguish when anatomical variation of arteries coexists. We report that sclerosing causes splenic infarction along abnormal LGA into spleen and indicate that pre-operative CTA combined with 3D visualization would be a valuable approach for visualizing vascular distribution and structural abnormality.

References

1. Tan YM, Goh KL, Kamarulzaman A, et al. Multiple systemic embolisms with septicemia after gastric variceal obliteration with cyanoacrylate. Gastrointest Endosc 2002;55:276-8.

Introduction

Cancer is the second leading cause of death globally. Colon cancer is the fifth most prevalent type of cancer. Screening, particularly colonoscopy, reduces incidence by 40% and mortality by 50%. The process of bowel preparation before a colonoscopy is complex and requires the patient’s compliance. Enhanced education using a smartphone application has been shown to improve bowel preparation quality. However, heterogeneity was observed among the studies.

Aims & Methods

AIMS: To determine if providing instructions through an application enhances bowel preparation quality in Thai patients undergoing elective colonoscopy.

METHODS: From July 2022 to January 2024, a prospective, endoscopist-blinded, randomized, controlled trial was conducted. Consecutive patients aged > 18 years old who had convenient access to the Line application were randomly assigned in a 1:1 ratio to be educated via the smartphone application (APP group) or the standard education (control group). All patients received the same purgative regimen. The primary outcome was the Boston Bowel Preparation Scales (BBPS). Secondary outcomes included adenoma detection and cecal intubation rates, cecal intubation time, withdrawal time, and patient satisfaction.

Results

The trial aims to recruit 488 patients. A total of 272 patients (APP group, n = 131; control group, n =141) were preliminary analyzed. The mean age was 61.5 years old, and 29% were male. The mean BBPS was comparable between the APP and control groups (8.30 ± 0.99 vs 8.51 ± 1.19, P = 0.173). Both groups achieved adequate bowel preparation (BBPS>6) in 99.2% of cases. All secondary outcomes corresponded with the primary outcome. In the subgroup analysis among the elderly, levels of education, income, and waiting times for colonoscopies, BBPS was not impacted by the providing methods. No adverse events related to education were observed.

Conclusion

Both standard and enhanced education using the smartphone application resulted in excellent bowel preparation. Eligible patients included in this study might influence this outcome. However, using the smartphone application was well-received and could potentially replace standard education for bowel preparation.

References

1. Virani S, Bilheem S, Chansaard W, Chitapanarux I, Daoprasert K, Khuanchana S, et al. National and Subnational Population-Based Incidence of Cancer in Thailand: Assessing Cancers with the Highest Burdens. Cancers. 2017;9(8):108.

2. May FP, Shaukat A. State of the Science on Quality Indicators for Colonoscopy and How to Achieve Them. Official journal of the American College of Gastroenterology | ACG. 2020;115(8):1183-90.

3. Desai M, Nutalapati V, Bansal A, Buckles D, Bonino J, Olyaee M, et al. Use of smartphone applications to improve quality of bowel preparation for colonoscopy: a systematic review and meta-analysis. Endosc Int Open. 2019;7(2):E216-E24.

Introduction

Non-invasive assessment of liver structure is an invaluable current practice of hepatology.
The rate of obesity is increasing globally. Africa is not an exception as obesity has become quite prevalent in many parts of Africa like Nigeria.
Steatosis (excessive fat in the liver) can be assayed in the liver using a controlled attenuation parameter (CAP) during transient elastography (TE).

Aims & Methods

All patients fasted for at least 3 hours prior to carrying out a Fibroscan. The level of fibrosis was recorded in kPa and the CAP in dB/m. The machine (Fibroscan Expert 630) also recorded the Shear wave speed (SWS) in meters per second. Height and weight were obtained using a Stadiometer and BMI was extrapolated. Biodata was obtained using a questionnaire

Results

One thousand four hundred and nine participants (1,409) were studied. The mean age was 43.84 (sd=14.27) years. About Sixty-five percent (64.84%) were males. The commonest (57.5%) indication for Fibroscan was Chronic Hepatitis B (CHBVI). Alcohol consumption and or suspicions of fatty liver disease made up about Nine percent (8.93%) of the indications. About 48% had higher-than-normal BMI.
About 81% had steatosis stage S0 (<248 dB/m). Nineteen percent had different degrees of steatosis. The largest group was S3 (280dB /m and above) with 9.6 %. Stage S1 (2458-267dB/m) was 5.7%. About 20% had significant fibrosis (14.0kPa and above) via TE measurement.
Age had a weak positive correlation (+0.185) with TE scores while BMI had a weak negative correlation (-0.162) with TE scores. On the other hand, the CAP score was strongly and positively (+0.461) correlated with BMI but negatively (-0.073) with SWS. P=0.001
On multiple regression, only BMI (B =4.09) significantly predicts CAP score by about 4 folds, p=0.0001.

Conclusion

The rate of obesity is increasing among adults in North-central Nigeria. Among this cohort, it’s clear that as BMI increases, the degree (Stage) of steatosis also increases.

Introduction

The prevalence of biliopancreatic malignancies is steadily increasing. Most patients are inoperable due to the typically advanced stage of the disease at the time of diagnosis and require biliary drainage. Despite numerous large-scale studies, the identification of predictive factors for survival in these cancers to improve their prognosis remains a challenge.
The aim of our study was to evaluate the survival of patients who underwent biliary stenting as part of the management of unresectable biliopancreatic malignancies and to assess the factors influencing the survival rate.

Aims & Methods

We conducted an observational cohort study between January 1, 2021, and March 28, 2024. All patients who underwent biliary drainage for obstructive jaundice due to biliopancreatic cancer (pancreatic head adenocarcinoma, peri-hilar cholangiocarcinoma, gallbladder cancer, ampulloma) were included. Contraindications to palliative chemotherapy were poor general condition (ECOG/WHO performance status 3 or more) and hyperbilirubinemia due to inadequate biliary drainage.

Results

82 patients were included in our study. The mean age in our series was 63.4 +/- 12 years. The sex ratio was 1. The median survival was 350 days (95% CI 268 – 514). 49.4% had pancreatic head adenocarcinoma, 30.6% had cholangiocarcinomas, 10% had ampullomas, and 10% had gallbladder cancer.
The median survival for pancreatic head adenocarcinoma was 450 days vs. 562 days for ampullomas, 356 days for cholangiocarcinomas, and 301 days for gallbladder cancer.
The type of cancer did not have a statistically significant difference on median survival (p = 0.95).
15% of patients had failed ERCP and underwent percutaneous biliary drainage. They had a 2.5 times higher risk of death (RR = 2.57, 95% CI 1.26-5.25, p = 0.01). Indeed, the median survival without death in cases of percutaneous drainage was 39 days vs. 375 in cases of successful ERCP (p = 0.007).
65% of patients were able to undergo palliative chemotherapy after stenting. The median survival with chemotherapy was 562 days vs. 30 days for patients who could not initiate it (p < 0.001). The latter had a 10 times higher risk of death in the month following stent placement (RR = 10.7, 95% CI 5.23-21.9, p < 0.001).
In our series, the presence of pancreatic head adenocarcinoma was associated with a higher probability of receiving chemotherapy (p = 0.04). However, it did not have a significant impact on median survival.
In multivariate analysis, only palliative chemotherapy seemed to improve the survival median (p < 0.001), while recurrence of jaundice and stent occlusion were associated with death (p = 0.03).

Conclusion

According to the results of our study, the prognosis of unresectable biliopancreatic cancers is poor but appears to be improved by a successful biliary stenting. Patients in whom biliary stent placement was a bridging procedure that allows chemotherapy seem to have higher survival rates. The generalization of endoscopic ultrasound-guided biliary drainage as an alternative to biliary percutaneous drainage could improve the survival rate in patients with failed ERCP.

Introduction

Faecal incontinence (FI) is a prevalent and debilitating anorectal problem which can cause embarrassment, anxiety, social isolation and diminishes quality of life (QoL). Currently, there is no optimal treatment option for FI, consequently, treatments primarily focus on symptom reduction and improving QoL. In order to gain a clearer understanding of the challenge’s patients encounter, it is essential to actively listen to patients’ perspectives and experiences, as well as the specific outcomes they aim to achieve from treatment.
This study aims to explore how FI impacts patients’ lives and identify important treatment outcomes as part of the development of a Core Outcome Set (COS).

Aims & Methods

Patients with FI were recruited from surgery and gastroenterology outpatient clinics in the Netherlands. Semi-structured interviews were performed, audio recorded, transcribed per verbatim and coded. Thematic analysis was performed to identify (sub)themes and categories relevant to the patients.

Results

Twelve interviews were conducted before saturation was reached (75% female, 25% male, mean age 63, range 39-83 year). Four main themes emerged ‘Physical symptoms’, ‘Impact on daily life’, ‘Emotional impact’ and ‘Coping’. Patients expressed how FI severely limits daily activities and emotional wellbeing. Patients' treatment priorities centred on resuming normal activities rather than solely on (physical) symptom reduction.

Conclusion

The impact of FI extends far beyond uncontrolled loss of faeces, affecting psychological, emotional, and social wellbeing. Patients prioritise outcomes focussed on reclaiming normalcy and independence rather than focusing on physical symptoms alone. Integrating these patient-centered outcomes in future studies could enhance treatment satisfaction and patient-perceived treatment success. Furthermore, outcomes identified through this study will be combined with other outcomes identified through literature review, forming a comprehensive list for a Delphi survey with relevant stakeholders to establish a consensus on a final list of outcomes for a COS for FI.

Introduction

Gastric emptying testing (GET) is used to assess gastric motility, however is non-specific and insensitive for neuromuscular disorders. Gastric Alimetry® is a new medical device combining non-invasive gastric electrophysiological mapping and validated symptom profiling.

Aims & Methods

This study aimed to assess patient-specific phenotyping using Gastric Alimetry with comparison to GET.
Patients with chronic gastroduodenal symptoms underwent simultaneous GET and Gastric Alimetry. Tests comprised a 30-minute baseline, ^99mTC-labelled egg meal, and 4-hour postprandial recording. Results were referenced to normative ranges^1,2. Symptoms were profiled in real-time during testing in the validated Gastric Alimetry App³, phenotyped with rule-based criteria, and compared to long-term symptom questionnaires of Rome IV criteria, Patient Assessment of Upper Gastrointestinal Symptom Severity Index (PAGI-SYM), Gastroparesis Cardinal Symptom Index (GCSI), Patient Assessment of Upper Gastrointestinal Disorders Quality of Life (PAGI-QoL), Patient Health Questionnaire-2 (PHQ-2), and State-Trait Anxiety Inventory-6 (STAI-6). Three Gastric Alimetry symptom profiles were phenotyped: i) continuous (symptoms do not correlate with meal or gastric activity); ii) gastric sensorimotor (symptoms increase within 30 minutes of the meal and decay as gastric activity decreases); and iii) Other (symptoms that do not fit the other two symptom profiles).

Results

75 patients with chronic gastroduodenal symptoms were assessed; 77% female, median age 43, median BMI 24.0. Motility abnormality detection rates were: GET 22.7% (14 delayed, 3 rapid); Gastric Alimetry spectral analysis 33.3% (14 dysrhythmic / low amplitude; 5 high amplitude; 6 abnormal frequency); combined yield 42.7%. In patients with normal spectral analysis, Gastric Alimetry symptom phenotypes included: gastric sensorimotor 17%; continuous 30%; other 53%. The sensorimotor phenotype correlated strongly with gastric amplitude (median r=0.61 vs r=0.08 and r=0.06 respectively; p=0.0002). Abnormal Gastric Alimetry phenotypes showed superior correlations with GCSI, PAGI-SYM, and STAI-6 anxiety scores (p<0.05), while Rome IV Criteria and delayed gastric emptying did not correlate (p>0.05). Delayed gastric emptying was not predictive of specific Gastric Alimetry phenotypes.

Conclusion

Gastric Alimetry generated a higher yield for motility abnormalities than GET in patients with chronic gastroduodenal symptoms. Gastric Alimetry also identified patient-specific symptom phenotypes, showing correlations with health psychology variables not observed with Rome IV and delayed gastric emptying. GET and Gastric Alimetry assess different aspects of gastric function, indicating these tests may have complementary roles.

References

1. Varghese C, Schamberg G, Calder S, et al. Normative values for body surface gastric mapping evaluations of gastric motility using gastric alimetry: Spectral analysis. American Journal of Gastroenterology 2022; Publish Ahead of Print. Epub ahead of print 2022. DOI: 10.14309/ajg.0000000000002077.
2. Abell TL, Camilleri M, Donohoe K, et al. Consensus recommendations for Gastric Emptying Scintigraphy: A joint report of the American Neurogastroenterology and Motility Society and the Society of Nuclear Medicine. Journal of Nuclear Medicine Technology; 36: 44–54.
3. Sebaratnam G, Karulkar N, Calder S, et al. Standardized system and app for continuous patient symptom logging in gastroduodenal disorders: Design, implementation, and validation. Neurogastroenterology & Motility 2022; 34. Epub ahead of print 2022. DOI: 10.1111/nmo.14331.

Disclosure

Greg O'Grady, Armen Gharibans and Peng Du hold intellectual property and grants in gastric electrophysiology and are Directors of University of Auckland spin-out companies (Greg O'Grady: Alimetry, Insides Company; Armen Gharibans: Alimetry; Peng Du: FlexiMap); Stefan Calder, Gabriel Schamberg, Stephen Waite, and Christopher N. Andrews are members of Alimetry. The remaining authors have no relevant conflicts of interest to declare.

Introduction

The biliary tree has traditionally been considered sterile under normal conditions¹. Recent evidence has revealed rich microbial communities in the biliary tract of patients affected by biliary tract disorders, supposing that biliary microbiota could play a significant role in the development of several biliary diseases, namely gallstones, autoimmune cholangiopathies, and cancer^2,3.
However, while possible connections between gut micro-organisms and biliary diseases has been studied more extensively, to date few evidences are available on how the microbiological composition may change disease’s progression⁴.
Not least it is still unclear how the modification of Oddi’s sphincter function after endoscopic sphincterotomy performed during an endoscopic retrograde cholangiopancreatography (ERCP) may represent a favorable environment for ascending bacterial colonization^5,6.

Aims & Methods

We performed a prospective observational study aimed to evaluate the prevalence of biliary pathogens of the bile in various disorders and to identify a microbial fingerprint for each disease. 162 consecutive patients with native papilla undergoing to ERCP for any indication were prospectively enrolled from July 2022 to April 2023. One bile sampling was performed after bile duct cannulation, before contrast injection and sphincterotomy, while a second one was done at the end of the procedure. Pre procedural clinical data, bile cultures and clinical follow-up were collected and analyzed.

Results

Biliary culture was obtained in 100% of patients. 52% of bile cultures were positive for at least 1 bacterium. No differences were found in microbial community before and after sphincterotomy. Out of 78 patients with positive bile cultures, 46 (59%) had cholangitis, all of them were under antibiotic therapy. Patients treated with immunomodulant agents did not have an increased risk of positive bile cultures. Multidrug-resistant bacteria were detected in pre-sphincterotomy bile cultures in 9 (5%) patients, of which 7 were extended-spectrum beta-lactamase (ESBL),1 Methicillin-resistant Staphylococcus aureus (MRSA) and 1 Vancomycin-Resistant Enterococci (VRE). No significant correlations were found between the presence of multidrug-resistant bacteria and underlying diseases, systemic cholangitis or immunomodulant exposure.

Conclusion

Our preliminary results showed how the biliary tree in patients with biliary diseases may not be sterile, even when Oddi’ s sphincter is intact. The presence of neoplastic diseases or immunosuppression therapy does not seem to correlate with an increase in positive bile cultures nor in multidrug resistant bacteria. Further analysis may be needed to assess the correlation between bile cultures and long-term outcomes.

References

1. Nicoletti, A. et al. Biliary tract microbiota: A new kid on the block of liver diseases? Eur. Rev. Med. Pharmacol. Sci. 24, 2750–2775 (2020).
2. Pereira, P., Aho, V., Arola, J., Boyd, S. & Jokelainen, K. Bile microbiota in primary sclerosing cholangitis : Impact on disease progression and development of biliary dysplasia. 1–15 (2017).
3. Chen, B., Fu, S. W., Lu, L. & Zhao, H. A preliminary study of biliary microbiota in patients with bile duct stones or distal cholangiocarcinoma. Biomed Res. Int. 2019, (2019).
4. Verdier, J., Luedde, T. & Sellge, G. Biliary Mucosal Barrier and Microbiome. Visz. Gastrointest. Med. Surg. 31, 156–161 (2015).
5. Ye, F. et al. Influence of the Biliary System on Biliary Bacteria Revealed by Bacterial Communities of the Human Biliary and Upper Digestive Tracts. 1–12 (2016). doi:10.1371/journal.pone.0150519
6. Schneider, J. et al. Risk factors for increased antimicrobial resistance : a retrospective analysis of 309 acute cholangitis episodes. 519–525 (2014). doi:10.1093/jac/dkt373

Disclosure

Cecilia Binda: Lecturer for Steris, Fujifilm, Q3 Medical, Boston Scientific
Chiara Coluccio: Lecturer for Steris
Carlo Fabbri: Lecturer for Steris, Q3 Medical, Boston Scientific