Introduction

Gastric cancer is one of the most common and lethal malignancies worldwide¹. A recognized independent risk factor for the development of this neoplasm is the presence of moderate-to-severe chronic atrophic gastritis (OLGA stage III-IV)^2,3.
In Italy regions with varying epidemiology for gastric cancer coexist. Notably, the Po Valley area, encompassing the provinces of Cremona and Mantua, is a high-risk region, with a standardized incidence rate of 32.2 cases per 100,000 men and 15.9 cases per 100,000 women⁴.

Aims & Methods

The present single-center retrospective observational study aims to evaluate the correlation between the incidence, over a period of approximately 10 years, of dysplastic and neoplastic lesions amenable to endoscopic resection and OLGA staging and other recognized risk factors for gastric cancer in this high-risk population.
We retrospectively analyzed all mucosal resections (EMR), submucosal dissections (ESD), and hybrid resections (Hybrid EMR/ESD) performed at our hospital between December 2014 and September 2024 for visible gastric lesions identified as low-grade dysplasia (LGD) or high-grade dysplasia (HGD) in pre-resection biopsies. For each patient, we collected demographic data, information on risk factors for gastric neoplasia, pre- and post-resection histology and details related to the endoscopic resection procedure. High Definition Chromo-Endoscopy (HD-CE) with at least 5 guided biopsies from antrum, incisura and corpus were performed concurrently with biopsy sampling of visible lesions and all specimens underwent to a second-look pathological examination.

Results

A total of 66 patients (36 males and 30 females) with a mean age of 74.7 years were included in the study. Pre-resection biopsies revealed low-grade dysplasia (LGD) in 62% of cases and high-grade dysplasia (HGD) in the remaining 38%. Forty-two patients underwent ESD, 14 EMR and 10 Hybrid EMR/ESD. However, in 3 patients the ESD procedure was discontinued due to massive intra-procedural bleeding, perforation and evidence of deep infiltration involving the muscularis propria. Examination of the resected specimens identified 29 lesions as LGD (44%), 17 as HGD (26%), 2 as intramucosal adenocarcinomas (3%), 14 as pT1a adenocarcinomas (21%), and 4 as pT1b adenocarcinomas (6%). Regarding risk factors: 9 patients (14%) had a first-degree family history of gastric neoplasia, while 16 patients (24%) were affected by Helicobacter pylori at the time the lesion was identified. The more interesting finding comes from the pre-resection OLGA staging: 4 patients had no gastric mucosal atrophy (OLGA 0), and 35 patients had early-stage chronic atrophic gastritis (15 OLGA I and 20 OLGA II). Among the remaining patients, 23 presented with OLGA stage III, and 4 with OLGA stage IV. Therefore, 59% of patients had an OLGA staging of II or lower at the time of the onset of the dysplastic or neoplastic lesion.

Conclusion

Our experience confirms what has already been observed in Asian countries: traditional risk factors for gastric neoplasia are insufficient in high-risk areas to identify the population that might benefit from short-term endoscopic follow-up.
These findings further support the statement included in the recently published update of the ESGE guidelines on the management of epithelial precancerous conditions and early neoplasia of the stomach (MAPS III), highlighting the need for periodic screening in high-risk populations regardless of additional risk factors⁵.

References

1. Smyth EC, Nilsson M, Grabsch HI, van Grieken NC, Lordick F. Gastric cancer. Lancet. 2020;396(10251):635-648. doi:10.1016/S0140-6736(20)31288-5
2. Rugge M, de Boni M, Pennelli G, et al. Gastritis OLGA-staging and gastric cancer risk: a twelve-year clinico-pathological follow-up study. Aliment Pharmacol Ther. 2010;31(10):1104-1111. doi:10.1111/j.1365-2036.2010.04277.x
3. Yue H, Shan L, Bin L. The significance of OLGA and OLGIM staging systems in the risk assessment of gastric cancer: a systematic review and meta-analysis. Gastric Cancer. 2018;21(4):579-587. doi:10.1007/s10120-018-0812-3
4. Val Padana Cancer Registry, ATS (Health Protection Agency) Val Padana, https://www.ats-valpadana.it/documents/1654672/64558781/Stomaco.pdf/3a88e15f-a32e-9344-a748-fdfa71f138ea
5. Dinis-Ribeiro M, Libânio D, Uchima H, et al. Management of epithelial precancerous conditions and early neoplasia of the stomach (MAPS III): European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter and Microbiota Study Group (EHMSG) and European Society of Pathology (ESP) Guideline update 2025. Endoscopy. 2025;57(5):504-554. doi:10.1055/a-2529-5025

Introduction

Artificial intelligence (AI) is playing an increasingly prominent role in gastrointestinal endoscopy, particularly in enhancing real-time lesion detection during colonoscopy. This study evaluates the impact of an advanced AI-assisted detection system on the Adenoma Detection Rate (ADR), Adenomas per Colonoscopy (APC), and predictive performance, comparing outcomes across endoscopists with different levels of experience.

Aims & Methods

Three endoscopists participated in the study: two with limited experience (Physicians A and B) and one expert (Physician C). A total of 720 colonoscopies were analyzed, with 400 procedures performed using AI assistance and 320 without, evenly distributed among the three operators.
Patients included were between 40 and 75 years of age and underwent colonoscopy either as a screening examination or following a positive fecal occult blood test. Exclusion criteria comprised a history of inflammatory bowel disease (IBD), hereditary polyposis syndromes, major colorectal surgery, or inadequate bowel preparation. For each procedure, data were collected on ADR, APC, the predictive accuracy of the AI system, and retraction time (from cecum to anus).

Results

The use of AI resulted in a marked and consistent improvement in all primary performance indicators across all three endoscopists.
In terms of ADR, Physician A improved from 23.8% without AI to 29.7% with AI; Physician B from 26.9% to 31.6%; and Physician C from 34.7% to 36.6%. Similarly, the APC index increased from 0.52 to 0.63 for Physician A, from 0.55 to 0.65 for Physician B, and from 0.64 to 0.73 for Physician C.
The AI system demonstrated high predictive accuracy across all operators, with no false positives recorded for polyps ≥4 mm in size. Prediction rates were 87.9% for Physician A, 89% for Physician B, and 92% for Physician C, confirming the device’s reliability in supporting polyp identification during real-time examination. Retraction times were slightly prolonged with AI usage: 8.3 minutes vs 7.5 for Physician A, 8.7 vs 7.4 for Physician B, and 8.8 vs 8.0 for Physician C. However, these differences did not reach statistical significance, indicating that AI support did not meaningfully affect procedural efficiency.

Conclusion

The integration of AI into colonoscopy workflows significantly improved both ADR and APC, with the most substantial impact observed in less experienced endoscopists. Physicians A and B, who initially showed suboptimal detection metrics, achieved levels of quality comparable to those of the expert operator in the absence of AI, highlighting AI’s value as a tool for bridging the gap in operator performance. The high predictive reliability of the system—particularly for clinically relevant lesions—and the absence of false positives ≥4 mm further support its clinical utility. Although retraction times increased slightly with AI, this change was not statistically significant, suggesting that the diagnostic advantages were not offset by decreased procedural efficiency. Overall, AI proves to be a valuable and scalable solution to enhance adenoma detection, support clinical training, and promote uniform quality standards in colorectal cancer screening.

References

1.Antonelli, G., Gkolfakis, P., Tziatzios, G., Papanikolaou, I. S., Triantafyllou, K., & Hassan, C. (2020). Artificial intelligence-aided colonoscopy: Recent developments and future perspectives. World journal of gastroenterology, 26(47), 7436–7443.
2.Hassan, C., Balsamo, G., Lorenzetti, R., Zullo, A., & Antonelli, G. (2022). Artificial Intelligence Allows Leaving-In-Situ Colorectal Polyps. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association, 20(11), 2505–2513.e4
3.Houwen, B. B. S. L., Hassan, C., Coupé, V. M. H., Greuter, M. J. E., Hazewinkel, Y., Vleugels, J. L. A., Antonelli, G., Bustamante-Balén, M., Coron, E., Cortas, G. A., Dinis-Ribeiro, M., Dobru, D. E., East, J. E., Iacucci, M., Jover, R., Kuvaev, R., Neumann, H., Pellisé, M., Puig, I., Rutter, M. D., … Dekker, E. (2022). Definition of competence standards for optical diagnosis of diminutive colorectal polyps: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement. Endoscopy, 54(1), 88–99.

Introduction

Inspection accuracy on colonoscopy is problematic because of the colon’s complex structure and the need for skillful operators. In particular, lesions in the ascending colon (AC) may be difficult to detect because of its high folds. Additionally, it has recently been reported that post-colonoscopy colorectal cancer is often located in the proximal colon. There are only a few reports on the effectiveness of retroflex inspection after forward view inspection in the AC during colonoscopy. While endoscopes and colonoscopy using artificial intelligence or image enhancement systems to detect lesions have been developed, it is important to reconsider basic endoscopic techniques, such as retroflex inspection, during colonoscopy.

Aims & Methods

We performed a prospective study to investigate the usefulness of retroflex inspection after forward view inspection in the AC during colonoscopy. Between August 2022 and December 2024, a single endoscopist enrolled and performed screening colonoscopies for 335 consecutive patients aged ≥40 years. Patients with inflammatory bowel disease, gastrointestinal polyposis, post-colorectal surgery, or poor preparation (≤1 point in at least one of three areas on the Boston Bowel Preparation Scale) were excluded from this study. The AC was inspected in this sequence: forward direction (Inspection 1), retroflex direction (Inspection 2), and forward direction (Inspection 3). The primary endpoint was the adenoma detection rate (ADR) in the AC. Secondary endpoints were the adenoma miss rate (AMR) in the AC per colonoscopy in Inspection 1 and Inspections 1+2, percentage of cases in which lesions were detected in Inspection 2, average observation time in the AC for each inspection, success rate of retroflexion in the AC, average pain score (0 points: no pain, 5 points: most severe pain), and complication rate during Inspection 2.

Results

We evaluated 300 patients with a median age of 66 years. The ADR in the AC for Inspection 1 vs. 1+2 was 18.7% vs. 28.7%, respectively (odds ratio: 1.749; 95% CI: 1.174–2.622; p = 0.005); the values for Inspection 1+2 vs. 1+2+3 were 28.7% vs. 30.0%, respectively (odds ratio: 1.066; 95% CI: 0.739–1.540; p = 0.788) (Table 1). The average AMR in the AC per colonoscopy for Inspection 1 vs. 1+2 was 12.6% (95% CI: 9.0%–16.2%) vs. 2.6% (95% CI: 0.8%–3.8%) (p < 0.001) (Table 1). The percentage of cases in which lesions were detected in Inspection 2 was 13.8% (41/298; total number of lesions: 47). The average diameter of lesions discovered and resected endoscopically during Inspection 2 was 6.1 mm (range: 3–20 mm). The locations of these lesions were as follows: proximal AC: 27.7% (13/47); mid-AC: 38.3% (18/47); and distal AC: 34.0% (16/47). The average observation times in the AC (Inspection 1 vs. 2 vs. 3) were 80.7 (95% CI: 77.8–83.6) vs. 59.1 (95% CI: 56.9–61.3) vs. 82.1 (95% CI: 79.4–84.8) seconds, respectively. The success rate of retroflexion in the AC was 99.3% (298/300), and the average pain score and complication rate during Inspection 2 were 0.5 points (95% CI: 0.4–0.6 points) and 0%, respectively.

Conclusion

Retroflex inspection following forward inspection in the AC during colonoscopy detects additional adenomas and is minimally invasive and safe. This technique contributes to improving the accuracy of colonoscopy.

Introduction

Acute severe ulcerative colitis (ASUC) is a potentially life-threatening emergency that requires timely management. Intravenous corticosteroids are the first line therapy, but around 30% of patients fail to respond. Rescue therapy is effective in reducing short-term colectomy rates but its impact on disease course in the medium/long-term is not well characterized.

Aims & Methods

We aimed to assess if non-response to corticoids (and subsequent need for rescue therapy) in patients admitted with a first episode of ASUC is associated with worse disease-related outcomes in the long-term.
We conducted a retrospective study of all patients admitted with ASUC in the Gastroenterology department of a Portuguese tertiary center between 2018-2024. ASUC diagnosis was established according to Truelove and Witts’ criteria. Response to intravenous corticoids was defined as discharge without need for rescue therapy and/or colectomy. Patients with a previous admission for ASUC before the study period were excluded.
Patient files were reviewed and demographic, clinical, laboratory and endoscopic data was collected regarding the admission for ASUC and subsequent follow-up. Considered disease-related outcomes were need for switch of maintenance therapy, need for readmission and need for colectomy. Subanalyses were performed according to response to corticoid therapy. Statistical analysis was done using Stata version 12.1.

Results

A total of 35 patients hospitalized with a first episode of ASUC were included, 51.4% (n=18) male, median age at admission was 38 years [IQR 27-51]. Roughly half the patients had pancolitis at diagnosis (51.4%, n=18). Median disease duration was 9 months [IQR 0-26] and 22.9% (n=8) had previous exposure to biologic therapy. In 34.3% (n=12), ASUC was the initial presentation of UC. Median follow-up was 30 months [IQR 12-51].
Response to corticosteroid therapy was observed in 57.1% (20/35). All the steroid-refractory patients (15/35, 42,9%) responded to rescue therapy (Infliximab n=11; Tacrolimus n=3; Tofacitinib n=1) and avoided colectomy during the hospitalization.
Baseline characteristics were identical between steroid-responsive and steroid-refractory patients, except for a lower median age in corticoid refractory patients (29 years vs 48 years, p=0.02).
Survival analysis was performed and no differences between steroid-responsive and steroid-refractory patients were observed in need for switch of maintenance therapy [during first year (p=0,28) and during complete follow-up (p=0,54)] , need for readmission [during first year (p=0,55) and during complete follow-up (p=0,54)] or need for colectomy [during first year (p=0,09) and during complete follow-up (p=0,79)].

Conclusion

In our cohort of patients with a first episode of ASUC, with the current therapeutic paradigm, patients with steroid refractoriness had similar outcomes as corticosteroid responders. These results suggest that effective and timely therapy can change the natural history of ASUC.

References

1. Festa S, Scribano ML, Pugliese D, Bezzio C, Principi M, Ribaldone DG, Allocca M, Mocci G, Bodini G, Spagnuolo R, Vernia P, Mazzuoli S, Costa F, Barberio B, Cosintino R, Zerboni G, Aratari A, Armuzzi A, Papi C. Long-term outcomes of acute severe ulcerative colitis in the rescue therapy era: A multicentre cohort study. United European Gastroenterol J. 2021 May;9(4):507-516. doi: 10.1177/2050640620977405. Epub 2021 Feb 16. PMID: 33259773; PMCID: PMC8259429.
2. Zafer M, Zhang H, Dwadasi S, Goens D, Paknikar R, Dalal S, Cohen RD, Pekow J, Rubin DT, Sakuraba A, Micic D. A Clinical Predictive Model for One-year Colectomy in Adults Hospitalized for Severe Ulcerative Colitis. Crohns Colitis 360. 2021 Dec 21;4(1):otab082. doi: 10.1093/crocol/otab082. PMID: 36777555; PMCID: PMC9802419.

Introduction

The NLRP3 inflammasome is crucial in regulating innate immune responses, balancing inflammation and homeostasis. It acts as a sensor for danger signals, facilitates the release of pro-inflammatory cytokines and plays a role in TGFβ, NF-κB, and IL-6/JAK/STAT3 signaling. Although the NLRP3 inflammasome is well known for its role in inflammation, recent studies suggest that it may also influence liver regeneration by modulating hepatocyte proliferation and tissue remodeling. This study investigates the role of the NLRP3 inflammasome and its related pathways in liver regeneration over time.

Aims & Methods

Using a partial hepatectomy mouse model, this research examines mRNA expression dynamics of NLRP3 and associated components post-surgery through RNA sequencing (RNA-seq). Liver tissue was analyzed at different time points after partial hepatectomy. Pathway analysis investigated the regulation of related signaling pathways, such as TGFβ, NF-κB, IL-6/JAK/STAT3, and endoplasmic reticulum stress responses.

Results

NLRP3 and Caspase-1 mRNA levels remained unchanged during liver regeneration. In contrast, mRNA expression of NLRP3 inhibitors, including Hsp90 and Sugt1 were significantly upregulated. Pathway analysis revealed substantial upregulation of TGFβ pathway during early proliferation phase, increased NF-κB signaling throughout the process, and consistent activation of the IL-6/JAK/STAT3 signaling pathway and endoplasmic reticulum stress responses.

Conclusion

These findings indicate the complex regulatory mechanisms of the NLRP3 inflammasome in liver regeneration and the varying pathway activation at different stages. Understanding the role of the NLRP3 inflammasome in liver regeneration could offer new insights into potential therapeutic approaches for patients with chronic liver disease or impaired hepatic recovery after surgery.

Introduction

The presence of bubbles during esophagogastroduodenoscopy (EGD) is common and may impair adequate mucosal visualization (MV).

Aims & Methods

The primary objective was to evaluate the effect of pre-endoscopic simethicone administration on mucosal visibility, using the GRACE (Gastroscopy Rate of Cleanliness Evaluation) scale. Secondary objectives included assessment of endoscopy duration, endoscopist satisfaction, and the detection rate of endoscopic findings.
This was a prospective, single-center, randomized, blinded study including patients undergoing elective EGD between December 2024 and March 2025. Patients were randomized into three groups: A (100 mg simethicone ≤10 minutes before EGD), B (100 mg simethicone >10 minutes before EGD), and C (50 mL water, placebo). All received a total volume of 50 mL. Patients with gastroparesis, achalasia, or prior gastrointestinal surgery were excluded. MV was assessed using the GRACE scale (validated in 2024), which scores each segment (esophagus, stomach, duodenum) from 0 to 3 based on bubble quantity, resulting in a total score from 0 (inadequate) to 9 (excellent). Endoscopist satisfaction was subjectively assessed on a scale from 0 (not satisfied) to 10 (highly satisfied).

Results

A total of 82 patients were included (18 in group A, 34 in group B, and 30 in group C). Fifty-two patients received 100 mg of simethicone and 30 received placebo. Median simethicone administration time was 8 minutes in group A and 19 minutes in group B. Simethicone significantly improved MV compared to placebo (mean GRACE score: 7.62±1.7 vs 5.83±1.7; p<0.001), with significant improvements in all segments (esophagus: 2.65 vs 2.03, p<0.001; stomach: 2.21 vs 1.63, p=0.002; duodenum: 2.69 vs 2.17, p=0.001). A very weak negative correlation was found between GRACE score and simethicone timing (r = -0.058; p = 0.685). Median endoscopist satisfaction was higher in the simethicone group (8 vs 7; p=0.001), and strongly correlated with total GRACE score (r = 0.855; p<0.001). No significant differences were observed in endoscopy duration (7 vs 6 minutes; p=0.800) or diagnostic yield (p=0.416).

Conclusion

Pre-endoscopic administration of simethicone significantly improved mucosal visibility across all upper GI segments, supporting its routine use in clinical practice. The GRACE scale is a useful and objective tool that correlates strongly with subjective endoscopist satisfaction.

References

Esposito G, Dilaghi E, Costa-Santos C, Ligato I, Annibale B, Dinis-Ribeiro M, Areia M; GRACE Investigators. The Gastroscopy RAte of Cleanliness Evaluation (GRACE) Scale: an international reliability and validation study. Endoscopy. 2025 Apr;57(4):312-320. doi: 10.1055/a-2422-0856. Epub 2024 Sep 25. Erratum in: Endoscopy. 2025 Apr;57(4):C2. doi: 10.1055/a-2545-0228. PMID: 39321961
Manfredi G, Bertè R, Iiritano E, Alicante S, Londoni C, Brambilla G, Romeo S, Menozzi F, Griffanti P, Brandi G, Moreschi O, Pezzilli R, Zullo A, Buscarini E. Premedication with simethicone and N-acetylcysteine for improving mucosal visibility during upper gastrointestinal endoscopy in a Western population. Endosc Int Open. 2021 Feb;9(2):E190-E194. doi: 10.1055/a-1315-0114. Epub 2021 Jan 25. PMID: 33532557; PMCID: PMC7834924.