Clinical Case Summary

Immune checkpoint inhibitors (ICI) revolutionized both treatment and outcome of multiple malignancies. However, they are frequently associated with immune-related adverse events (irAE), commonly affecting the gastrointestinal tract with an increased incidence and severity when combining agents.
A 41-year-old man presented with abdominal pain and bloody diarrhea after treatment with dual ICI therapy for lymphogenic progression after partial nephrectomy in the past. The initial work-up revealed positive stool samples for C.difficile – antibiotic treatment with negativization of stool samples was completed with no significant improvement. A colonoscopy was then performed, revealing severe ulcerative pancolitis with no ileal involvement. Based on the use of ICI 40 days prior to manifestation, the diagnosis of immune-related pancolitis was made. Local and systemic steroids at 1 mg/kg were initiated, achieving clinical remission. ICI therapy was permanently discontinued.
During steroid tapering a clinical relapse occurred – dosage was increased to 2 mg/kg with only partial improvement. A follow-up colonoscopy showed moderate pancolitis with a narrow fistula 30cm above the dentate line with an intraluminal free-moving foreign body (clips) from the nephrectomy, which was not detected on MRI. A second line therapy with three intravenous infusions of Vedolizumab was applied. A complete clinical response (resolvement of diarrhea and normalization of calprotectin levels) was achieved for three months, followed by a new relapse of symptoms with endoscopically confirmed moderate pancolitis. Considering the chronically recurrent course, the patient was put on an ongoing Vedolizumab treatment with no further relapses up to present date.
Immune-related colitis is a condition with an unpredictable natural course. Not all patients benefit from induction therapy only. Nevertheless, the duration of immunosuppressive treatment for long-term remission remains unclear at times.

References

1. Colonoscopy revealing severe ulcerative pancolitis
2. Follow up colonoscopy with a free moving foreign body
3. MRI and CT findings

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) is a widely utilized procedure for managing biliary and pancreatic disorders (1). ERCP is associated with complications, and potential factors influencing the ERCP outcomes is a critical area of research (2). Among these factors, obesity has emerged as a variable of interest due to its increasing prevalence globally and its known associations with a range of health conditions (3). Previous studies have yielded conflicting results on the influence of obesity on ERCP outcomes, with some reporting higher complication rates, while others found no significant associations (4, 5). The interplay between weight and procedural outcomes across a spectrum of BMI categories remains underexplored. This study aimed to assess the impact of body mass index (BMI) on clinical aspects and procedural outcomes of ERCP.

Aims & Methods

A total of 2143 patients who underwent ERCP at Hitit University Hospital between January 2020 and February 2024 were initially included. Of these, 1315 patients were excluded due to incomplete clinical information, previous ERCP history, altered anatomy and pregnancy, resulting in a final cohort of 828 patients for analysis.
The included patients were stratified into BMI categories: ≤30 kg/m² and >30 kg/m². Additionally, subgroup analyses were performed across finer BMI classifications: ≤20, 20 to ≤25, 25 to ≤30, 30 to ≤35, and >35 kg/m². Clinical and procedural parameters evaluated included admission diagnoses of acute pancreatitis and acute cholangitis (according to Tokyo cholangitis grade), American Society of Anesthesiologists (ASA) scores, gender, history of cholecystectomy, cannulation success, cannulation time, post-ERCP complications including post-ERCP pancreatitis and other complications according to modified Cotton criteria and 30-day readmission rates. The relationships between BMI and the clinical aspects as well as procedural outcomes of ERCP were investigated.

Results

The study cohort consisted of 828 patients, with 75.8% (n=628) having a BMI ≤30 kg/m² and 24.2% (n=200) having a BMI >30 kg/m². Within the finer BMI categories, 3.7% (n=31) of patients had a BMI ≤20 kg/m², 24.2% (n=200) were in the 20 to ≤25 kg/m² range, 47.9% (n=397) were in the 25 to ≤30 kg/m² range, 19.7% (n=163) were in the 30 to ≤35 kg/m² range, and 4.5% (n=37) had a BMI >35 kg/m². The majority of patients (47.9%) were within the BMI range of 25–30 kg/m², reflecting a significant proportion of overweight individuals in the cohort. Patients with a BMI >35 kg/m² constituted the smallest group, accounting for only 4.5% of the total population.
The study found no statistically significant differences between the groups concerning admission rates for acute pancreatitis and acute cholangitis, ASA scores, cannulation success, post-ERCP complications, and readmission within 30 days after the procedure (p>0.05). Notably, women were found to be significantly more obese (p<0.001), and a higher weight was associated with an increased history of cholecystectomy (p=0.013).
Additionally, there were no significant differences in average age, Charlson comorbidity index, cannulation time, length of hospital stay, or white blood cell count at admission between the BMI groups (p>0.05). However, CRP and total bilirubin levels were significantly higher in the non-obese group compared to the obese group (p=0.01 and p=0.011, respectively).

Conclusion

BMI did not influence the incidence of acute pancreatitis or acute cholangitis on admission, ASA scores, cannulation success or time, post-ERCP complications, length of hospital stays, or 30-day readmission rates. Interestingly, higher CRP and total bilirubin levels were observed in patients without obesity at admission, warranting further investigation into their clinical implications.

References

1. Tokmak S TS. History of ERCP. The Turkish Journal of Academic Gastroenterology 2021;20: 1-2.
2. Duzenli T, Koseoglu H. Endoscopic Retrograde Cholangiopancreatography During the COVID-19 Pandemic: Effects of Enhanced Personal Protective Equipment. Dig Dis Sci 2021;66: 1845-1851.
3. Alfaris N, Alqahtani AM, Alamuddin N, Rigas G. Global Impact of Obesity. Gastroenterol Clin North Am2023;52: 277-293.
4. Deenadayalu VP, Blaut U, Watkins JL, Barnett J, Freeman M, Geenen J, et al. Does obesity confer an increased risk and/or more severe course of post-ERCP pancreatitis?: a retrospective, multicenter study. J Clin Gastroenterol2008;42: 1103-1109.
5. Fujisawa T, Kagawa K, Hisatomi K, Kubota K, Sato H, Nakajima A, et al. Obesity with abundant subcutaneous adipose tissue increases the risk of post-ERCP pancreatitis. J Gastroenterol 2016;51: 931-938.

Introduction

Abdominal pain is a common symptom in clinical settings, but its prevalence and impact on individuals in the global population are poorly understood.

Aims & Methods

We aimed to use the population-based Rome Foundation Global Epidemiology Study (RFGES)¹ dataset to assess the prevalence and burden of abdominal pain in the global population. Data from all 54127 individuals in 26 countries covering 6 world regions (Asia, Middle East, Eastern Europe, Western Europe, North America, and Latin America) surveyed via the Internet (49.1% females; mean age 43.7 years, range 18-97) were included in the analyses. The survey included the Rome IV diagnostic questionnaire, the PROMIS Global-10 quality of life (QoL) questionnaire, the Patient Health Questionnaire PHQ-4 (anxiety and depression), and questions about medical history and healthcare utilization. Survey respondents who reported pain anywhere in the abdomen in the past 3 months were classified as abdominal pain cases, and all others as controls.

Results

Abdominal pain was reported by 51.9% (95% CI: 51.4, 52.3) of people in the global sample. The prevalence was higher among women than men [59.6% (59.0, 60.1) vs. 44.4% (43.8, 45.0)], and declined across age groups: 60.5% (59.8, 61.2) for ages 18 to 34, 54.6% (53.8, 55.4) for ages 35 to 49 years, 45.5% (44.6, 46.4) for 50-64 years, and 37.7% (36.7, 38.7) for 65+ years. Abdominal pain prevalence varied markedly between world regions, from a low of 41.2% (40.2, 42.2) in Asia to a high of 66.5% (65.3, 67.7) in Eastern Europe. Among the 26 individual countries, it ranged from 32.1% (30.2, 33.9) in Japan to 69.3% (67.2, 71.3) in Egypt.
Individuals with abdominal pain were twice as likely as controls to meet criteria for one or more of the 22 disorders of brain-gut interaction (DGBI) assessed [54.2% (53.6, 54.8) vs. 25.0% (24.5, 25.5)] and more than twice as likely to report a history of organic gastrointestinal disorders: [9.8% (9.4, 10.1) vs. 4.2% (3.9, 4.4)]; p<0.0001 for both. However, 38.9% of people with abdominal pain neither met DGBI criteria nor had organic GI disease history.
People with abdominal pain had significantly lower physical and mental quality of life scores than controls, showed more impairment in work productivity and life activities, were more likely to have ever visited a doctor because of a bowel problem, and more likely to visit doctors frequently (at least monthly) for any health reasons. They also more commonly reported being concerned about their bowel functioning. For details see Table 1.

Conclusion

Abdominal pain affects half the adult global population, including many people who have no GI disorders. It is more common in women, younger individuals, and people in non-Asian countries. Having abdominal pain is associated with poorer quality of life, impaired work and life functioning, increased psychological symptoms and greater healthcare utilization. These findings underscore that abdominal pain, as a symptom rather than only as a part of diagnosed disorders, warrants attention by healthcare services and researchers to better address unmet needs of sufferers.

References

1. Sperber et al. Worldwide Prevalence and Burden of Functional Gastrointestinal Disorders, Results of Rome Foundation Global Study. Gastroenterology. 2021 Jan;160(1):99-114.e3. doi: 10.1053/j.gastro.2020.04.014.

Disclosure

BBDF, CA and RL are currently employees of Opella, a Sanofi company and may hold shares or stock options in the company. OSP receives licensing fees from MetaMe Health. MS has received unrestricted research grants from BioGaia; served as consultant/advisory board member for Biocodex, Tillotts, BioGaia, Renapharma, and AlfaSigma; and served on speakers' bureau for Tillotts, Takeda, Biocodex, Sanofi, Abbvie, Janssen Immunology, Pfizer, BioGaia, Renapharma, Mayoly and Bromatech. JT has given scientific advice to Aclipse, Adare, AlfaSigma, Bio-Codex, Clasado, Danone, Falk, FitForMe, Ironwood, Kyowa Kirin, Menarini, Promed, Ricordati, Takeda, Tsumura and Truvion Pharmaceuticals; received research support from Biohit, Kiowa Kirin, ProMed, Sofar, Takeda and Tsumura; and served on the speaker bureau for Abbott, Bio-Codex, Mayoly, Menarini, ProMed, Reckitt-Benckiser, Schwabe, Takeda, Thai Meiji and Truvion Pharmaceuticals. JH, DAD, ADS and SIB have no conflicts of interest to declare.

Clinical Case Summary

Background: Crohn’s disease (CD) is a chronic inflammatory condition frequently managed with biologic therapies. While venous thromboembolism (VTE) is a recognized complication in inflammatory bowel disease (IBD), certain biologics, including JAK2 inhibitors, have been linked to increased thrombotic events. This case report describes a rare instance of recurrent, unprovoked pulmonary embolism (PE) in a CD patient receiving Vedolizumab (VDZ).
Case presentation: A 45-year-old male with a long-standing history of CD experienced recurrent disease flares. His medical history included an ileo-colonic resection and anastomotic revision, after which he developed a provoked PE requiring long-term anticoagulation. Previous treatments, including infliximab, Adalimumab, Ustekinumab, Methotrexate, and 6-MP, had failed before he was started on VDZ monotherapy, which effectively controlled his colitis. Despite intensified anticoagulation, he had four hospitalizations for unprovoked PE within a year. A comprehensive hematologic evaluation, reviewed by a consultant haematologist, ruled out any underlying thrombophilic disorders. Given concerns about a potential association between VDZ and recurrent VTE, the medication was discontinued, and the patient was transitioned to Risankizumab. After four months, no further VTE episodes were reported.
Discussion & conclusion: Emerging evidence, including a study by Cross et al. (2017), suggests that patients treated with VDZ have a higher risk of thrombotic complications. This case highlights a potential, yet rare, association between Vedolizumab and recurrent PE in CD patients. Clinicians should remain vigilant when prescribing VDZ, particularly in patients with a history of thromboembolic events. Further research is needed to explore this association and guide clinical decision-making.

References

https://www.researchgate.net/publication/316370555_The_Incidence_of_Cardiovascular_Events_in_Patients_with_Crohn's_Disease_Treated_with_Vedolizumab_and_Anti-TNF_Therapies

Disclosure

No Conflict of Interest

Introduction

A surge in endoscopy requests, often discordant with International guideline recommendations, is overburdening services and wasting resources. Evidence suggests that up to 20-30% of upper gastrointestinal (GI) endoscopies and colonoscopies are inappropriate^1,2, and each procedure carries a significant carbon footprint (5.43 kg CO₂ for an upper GI endoscopy and 6.71 kg CO₂ for a colonoscopy)³. AI‑driven language models, such as ChatGPT, hold promise as decision‑support tools to help triage these requests. However, their efficacy in this context has yet to be validated.

Aims & Methods

The aim of this study was to compare ChatGPT o4-Mini’s appropriateness assessments with those of expert clinicians and model the potential environmental and economic benefits of reducing unnecessary procedures through AI-assisted decision making. Between February and April 2025, we prospectively collected endoscopy referrals from primary care physicians and other specialists to our tertiary referral centre. Each case was entered into ChatGPT-o4 Mini’s blank prompt, and appropriateness was evaluated according to the European and American guidelines. Two expert gastroenterologists independently reviewed the same referrals, and their assessment was used as Ground Truth.

Results

We evaluated 126 consecutive endoscopic examinations: 75 (60%) colonoscopies, 49 (39%) upper GI endoscopies, and 2 (1%) flexible sigmoidoscopies (FS). Overall, 21% of the endoscopic procedures were deemed inappropriate by expert review, and in particular 20% of colonoscopies, 20.4% of upper GI examinations, and 50% of FS. ChatGPT-o4 Mini demonstrated a comparable appropriateness estimate (AUC 0.91, 95% CI 0.83-0.98, sensitivity 99%, specificity 84%) to that provided by experts. Inter-rater agreement between experts and ChatGPT-o4 Mini appropriateness ratings was assessed using Cohen’s kappa and it results k = 0.87 indicating excellent agreement. In our simulated model, AI‑driven triage avoided 14 colonoscopies and 8 upper GI endoscopies, resulting in a reduction of 93.94 kg CO₂ per colonoscopy and 48.9 kg CO₂ per upper GI endoscopy, for a total carbon footprint saving of 142.84 kg CO₂.

Conclusion

ChatGPT‑o4 Mini demonstrated accuracy in assessing endoscopy appropriateness, with potential to reduce unnecessary procedures and their carbon footprint. With targeted training on clinical guidelines and referral data, such AI tools could act as autonomous triage filters, minimizing reliance on human reviewers. This approach may streamline resource allocation, enhance sustainability, and support guideline-adherent care. Further validation in real-world settings is warranted.

References

1. Zullo A, Manta R, De Francesco V, Fiorini G, Hassan C, Vaira D. Diagnostic yield of upper endoscopy according to appropriateness: A systematic review. Dig Liver Dis. 2019;51: 335–9.
2. Frazzoni L, La Marca M, Radaelli F, Spada C, Laterza L, Zagari RM, et al. Systematic review with meta-analysis: the appropriateness of colonoscopy increases the probability of relevant findings and cancer while reducing unnecessary exams. Vol. 53, Aliment Pharmacol Ther 2021; 53:22–32.
3. Elli L, La Mura S, Rimondi A, Scaramella L, Tontini GE, Monica F, et al. The carbon cost of inappropriate endoscopy. Gastrointest Endosc 2024;99:137-145.e3.

Introduction

Pre-cut sphincterotomy are most often used as a salvage procedure after failure of conventional methods of bile duct cannulation although its success is not guaranteed.　
When we performed initial pre-cut sphincterotomy, papilla is incited, with needle knife or sphincterotome, until the opening of bile duct is recognized to gain access to its lumen.
Our technique, in cases of not recognized the opening of bile duct, involves engaging the exposing underlying submucosal tissue layer of the papilla with the catheter and then seeking bile duct with the hydrophilic guide wire, completely dependent on fluoroscopic view.
The purpose of this study was to assess the efficacy and safety of our technique in cases of failed pre-cut.

Aims & Methods

We retrospectively analyzed the clinical records of consecutive patients undergoing ERCP between 1 January 2009 and 31 October 2024 at Mitsui Memorial Hospital, Tokyo, Japan.
Patients who underwent an ERCP plus pre-cut were included.
Patients were divided into two groups, in whom the common bile duct could be cannulated (Group A), and the common bile duct could not be cannulated and our technique was performed(Group B), after initial pre-cut.
The primary objective was a successful biliary cannulation, and the secondary objective was the complication in group B.
The complications and patient characteristics were compared between group A and B using Fisher’s exact test.

Results

Over a period of fourteen years ten months, 262 Pre-cut sphincterotomy (Needle knife sphincterotomy 108, Transpancreatic septotomy 126, Both 28) were performed. After initial pre-cut, we could achieve biliary access in 183 (Group A), and could not in 79. We performed our technique in 77 among these 79(group B).
In Group B, the therapeutic indications for ERCP were choledocholithiasis in 44 (57.1%) of cases, malignant and benign biliary obstruction in 29(37.7%) and 4(5.2%). The average age of the patients was 73 years (range 29-96) and 45 (58.4%) were male. Among 77 patients, a successful biliary cannulation was achieved in 72 (93.5 %). Complications were 15(19.5%). 2 patients presented bleeding (2.6 %) and required endoscopic treatment and transfusion of red blood cells. 9 (11.7 %) patients developed post-ERCP pancreatitis (1 severe, 8 mild pancreatitis). Guidewire related perforations that were resolved with conservative management occurred in 4(5.2%).
Alerted anatomy status was more frequently observed in group B than group A (p < 0.01). The other characteristics of both groups were similar. Total complications were more frequently observed in group B (p ＝ 0.03).

Conclusion

Our technique in cases of failed pre-cut sphincterotomy is found to be highly effective method to get biliary access, but carried a higher adverse event rate.