Introduction

Colorectal cancer (CRC) is the third most common cancer and the second cause of cancer-related deaths worldwide [1]. Although the biological pathways that transform the normal colon tissue into malignant tissue are different, polyps are presumed to be the precursor lesions for malignant tumors in all cases[2]. Colorectal polyps (CRP) can be seen in various forms or shapes on colonoscopy. Convolutional neural networks (CNNs) are a class of deep neural networks used for different clinical purposes, including improving the detection rate of colorectal lesions.

Aims & Methods

This systematic review and meta-analysis aimed to assess the performance of CNN-based models in the detection or classification of colorectal polyps (CRP) and colorectal cancer (CRC). A systematic search was performed in MEDLINE, SCOPUS, Web of Science, and other related databases. The performance measures of the CNN models in the detection of CRP and CRC were calculated in the two scenarios of the best and worst accuracy. Stata and R software were used for conducting the meta-analysis.

Results

From 3368 searched records, 24 primary studies were included. The sensitivity and specificity of CNN models in predicting CRP in worst and best scenarios ranged fr3om 84.7-91.6% and 86.0-93.8%, respectively. These values in predicting CRC varied between 93.2-94.1% and 94.6-97.7%. The positive and negative likelihood ratios varied between 6.2-14.5 and 0.09-0.17 in these scenarios, respectively, in predicting CRP, and 17.1-41.2 and 0.07-0.06 in predicting CRP. The diagnostic OR and accuracy measures of CNN models in predicting CRP in worst and best scenarios ranged between 36-162 and 80.5-88.6%, respectively. These values in predicting CRC in the worst and the best scenarios varied between 239.63-677.47 and 88.2-96.4%. The area under the ROC varied between 0.92 to 0.97 in the worst and the best scenarios in CRP, respectively, and 0.98 to 0.99 in CRP prediction.

Conclusion

CNN-based models showed an acceptable accuracy in detecting CRP and CRC.

References

1. Keum NN, Giovannucci E. Global burden of colorectal cancer: emerging trends, risk factors and prevention strategies. Nat Rev Gastroenterol Hepatol 2019;16:713-732.
2. Øines M, Helsingen LM, Bretthauer M, Emilsson L. Epidemiology and risk factors of colorectal polyps. Best Pract Res Clin Gastroenterol 2017;31: 419–24.

Disclosure

Not to declare

Introduction

Esophageal food bolus obstruction (FBO) is a common presentation to Emergency Departments worldwide¹. There remains a paucity of data relating to efficacy of pre-endoscopic and endoscopic management resulting in a wide variety of clinical practice. Consensus guidelines do not advocate strongly for pre-endoscopic medications however they remain commonly used^2,3. This study evaluated the safety and efficacy of pre-endoscopic and endoscopic treatment in successful clearance of FBO and assessed the prevalence of underlying esophageal pathology.

Aims & Methods

ICD-10 codes retrospectively identified adult patients ≥18 years admitted to the Monash Health network (Melbourne, Australia) with esophageal FBO from 2010 to 2021. Medical records were reviewed to determine baseline characteristics, medical and endoscopic treatments and outcomes. Pre-endoscopic therapies included glucagon, glyceryl trinitrate (GTN), buscopan and Coca Cola. Multivariable analysis was performed to determine factors associated with pre-endoscopic clearance of FBO.

Results

608 patients were included. The median age was 56 years (IQR 39 – 71) and 405 (66.6%) were male. A prior history of FBO was noted in 228 (37.5%) patients, 110 (18.1%) had gastro-oesophageal reflux disease, 71 (11.7%) had dysphagia and 51 (8.4%) had a history of esophageal strictures. Inability to swallow saliva was noted in 296 (49.7%) patients at presentation.
Pre-endoscopic therapy was administered to 389 (64.0%) patients with a mean of 2 medications prescribed. Glucagon (47.4%), GTN (37.2%) and Coca Cola (36.3%) were most commonly administered. Successful FBO clearance was documented in 36.8% patients receiving medical therapy (glucagon 35.1%, GTN 36.2%, Coca Cola 38.0%); no individual medication significantly reduced the need for endoscopic intervention. Multi-variable analysis demonstrated that tolerating saliva (OR 1.95, p=0.025) and liquids (OR 2.28, p=0.001) significantly predicted spontaneous resolution of the EFBO without endoscopy.
474 (78.0%) patients proceeded to endoscopy. Median time to endoscopy was 14 hours (IQR 6 – 16) with 36.1% patients intubated for the procedure. The FBO was most commonly located in the lower esophagus (32.7%). The most common endoscopic findings were esophagitis (30.2%) and peptic ulcer disease (18.8%), with 3 (0.6%) malignancies identified. Endoscopic complications occurred in 35 (7.4%) patients (partial esophageal tear (n=24), aspiration pneumonia (n=5)). At endoscopy, a cause for the FBO was found in 130 (27.4%) patients, most commonly due to esophageal strictures (13.9%), eosinophilic esophagitis (11.2%) and Schatzki rings (9.1%). Esophageal biopsies were taken in 155 (32.7%) patients, of which 34.2% reached the diagnostic criteria for eosinophilic esophagitis.

Conclusion

Despite limited evidence, pre-endoscopic medical treatment of FBO is safe, commonly utilised, and results in spontaneous clearance in 36.8% patients. Patients’ clinical symptoms, in particular the ability to tolerate saliva or liquids, is the best predictor for spontaneous FBO clearance. Endoscopy remains highly effective and has a low complication rate.

References

1. Longstreth GF, Longstreth KJ, Yao JF. Esophageal food impaction: Epidemiology and therapy. A retrospective, observational study. Gastrointest Endosc. 2001;53(2):193-198. doi:10.1067/mge.2001.112709
2. Ikenberry SO, Jue TL, Anderson MA, et al. Management of ingested foreign bodies and food impactions. Gastrointest Endosc. 2011;73(6):1085-1091. doi:10.1016/j.gie.2010.11.010
3. Birk M, Bauerfeind P, Deprez P, et al. Removal of foreign bodies in the upper gastrointestinal tract in adults: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2016;48(05):489-496. doi:10.1055/s-0042-100456

Introduction

Sarcopenia defined as having low muscle mass, muscle strength and if combined with low performance indicate severe sarcopenia¹. It is associated with adverse outcomes in cirrhosis, including hepatic encephalopathy, ascites, infection, and increased hospitalisation. Prevalence of sarcopenia has been reported between 40 to 70% and are more common with alcoholic liver disease².

Aims & Methods

We aim to assess relationship between nutritional status/assessment, muscle quality and sarcopenia. Cirrhotic patients were recruited from a tertiary-hepatology-clinic for this prospective cross-sectional study. BIA was performed as the standard (SECA mBCA-525) for nutritional status and sarcopenia assessment. Appendicular skeletal muscle mass (ASM) calculated through sum of limb muscle masses in kg. sarcopenia was diagnosed with ASM/height²<7.0 kg/m² and <5.5 kg/m² for male and female respectively. Muscle quality was measured by mean handgrip strength in kg divided by ASM (HGS/ASM). Validated functional muscle metrics (handgrip and sit-to-stand), liver-frailty-index (LFI)³, Chronic Liver Disease Questionnaire (CLD-Q)⁴ and food-frequency-questionnaire (FFQ) were also analysed.

Results

49 patients, 57% (28) alcohol-liver-disease, 18% (9) non-alcoholic steatohepatitis, 5% (4) viral, 4% (3) autoimmune and 7% (5) mixed aetiologies, were included. 44 healthy controls (HC) were recruited as well. Most patients were male (n=28, 57%), with mean age 56yrs (SD=9), mean Child-Pugh score 6 (IQR= 5-7) and MELD 10 (IQR= 7-12). 35% (n=17) were actively drinking alcohol. 9 (18%) of patients were frail and 34 (69%) were pre-frail. 25 (89%) cirrhotic male and 14 (66%) cirrhotic female had sarcopenia diagnosed via BIA. 24/42 (57%) had lower total daily energy intake than is recommended by EASL guidelines⁵. Of those, 11 (44%) male and 6 (42%) had diagnosis of sarcopenia.
There was positive correlation between nutritional status measured with BIA as Phase angle analysis (PhA) with total skeletal muscle mass adjusted for height, SMM/H², (r=0.51, p<0.0001) and ASM/H² (r=0.04,p=0.7). There was strong correlation between PhA and HGS (r=0.71, p=<0.001). Higher PhA score predicts lower MELD score therefore longer survivals (β = -0.092, p=0.004).
Healthy control has significantly better muscle quality (HGS/ASM) compared to cirrhotic patient (mean 2.52 vs 1.85 kg, SD 0.6 and 0.4 respectively, p<0.001).
Using functional testing, sit-to-stand time was lower in HCs (13.35 vs 8.94 secs, p=0.0001) and hand-grip strength higher in HC (p< 0.001). QoL was negatively correlate with sarcopenia (r=-0.06,p=0.6), LFI (r=-0.2,p=0.1), MELD (r=-0.15,p=0.3) and Child-Pugh score (r= -0.08, p=0.6) although they were not statically significant.

Conclusion

Cirrhotic patients had lower muscle quality and functional status compared to HC. FFQ and PhA are good assessment tool to establish nutritional status. PhA correlated much better with SMM/H2 than ASM/H2 and is a good predictor for disease severity. QoL is multifactorial and couldn’t be explained with frailty scores or clinical severity scores.

References

1. Alfonso J Cruz-Jentoft et al. Sarcopenia: revised European consensus on definition and diagnosis. Age Ageing 2019 Jan 1;48(1):16-31
2. Xinxing Tantai et al. Effect of sarcopenia on survival in patients with cirrhosis: A meta-analysis Journal of Hepatology 2022 vol. 76 j 588–599
3. Jennifer C Lai et al. Development of a novel frailty index to predict mortality in patients with end-stage liver disease. Hepatology 2017 Aug;66(2):564-574
4. Z M Younossi et al. Development of a disease specific questionnaire to measure health related quality of life in patients with chronic liver disease. Gut 1999;45:295–300
5. EASL Clinical Practice Guidelines on nutrition in chronic liver disease. J Hepatol. 2019 Jan;70(1):172-193.

Introduction

The impact of achieving endoscopic remission in ulcerative proctitis (UP) is unclear. The preferred long-term treatment goal in ulcerative colitis (UC) is achieving both the symptomatic resolution and endoscopic remission (ER),¹ which has been associated with reduced risk of complications, including colectomy.^2,3 UP is an anatomically limited form of UC, involving only the rectum. Unlike in extensive or left-sided UC, UP has not been associated with elevated colorectal cancer risk. Therefore, the achievement of endoscopic healing as compared to clinical remission in UP represents an uncertain therapeutic target.⁴

Aims & Methods

This study assessed the impact of achieving EH on subsequent outcomes in UP patients. This was a single-center retrospective cohort study including patients aged ≥ 18 with a confirmed diagnosis of UP based on clinical and endoscopic criteria. Included patients had at least two endoscopies and active endoscopic disease (Mayo endoscopy score [(MES) of 1, 2, or 3]) at the first (baseline) endoscopy. EH was defined as an MES of 0 or 1 at the second (follow-up) procedure. A minimum time of 1 month between scopes was required for inclusion. Descriptive statistics were used for baseline characteristics. The relationship of EH to IBD-related outcomes was assessed using univariate analysis (Pearson's Chi-squared test; Fisher's exact test; Welch Two Sample t-test) and we identified those independently associated with EH using multivariable logistic regression analysis (odds ratio with 95% confidence interval).

Results

Among 200 UP patients with baseline endoscopic activity, 109 patients (54.5%) achieved EH at follow-up. The median time from baseline to follow-up was 15 months (IQR: 6, 31). EH at follow-up was significantly associated with fewer IBD-related ED visits (healing: 8.3%, no healing: 21%) or hospitalizations (5.5% vs 18%) and fewer GI visits (mean: 8 [SD: 9], vs 17 [22]) after the second scope. Patients with EH were less likely to have iron deficiency anemia (IDA; 23% vs 41%), iron infusion (10% vs 25%), C. difficile infection (0.9% vs 6.6%), or to initiate a new biologic after relapse (15% vs 33%). Patients with EH also had a greater time to clinical relapse (650 days [730] vs 270 days [416]). In multivariable analysis, patients with mucosal healing had 68% lower odds of an IBD-related ED visit (OR: 0.32, 95% CI: 0.13, 0.73), 74% lower odds of IBD-related hospitalization (0.26 [0.09, 0.67]), and 64% lower odds of biologic initiation after relapse (0.36 [0.13, 0.95]) compared to patients with no mucosal healing, adjusting for the index MES score.

Conclusion

UP patients with endoscopic healing had less IBD-related healthcare utilization (ED visits, hospitalizations, GI visits), fewer IBD-related complications (IDA, iron infusion, C. difficile infection), and were less likely to escalate to biologics after relapse. Our findings suggest that using a treatment target of endoscopic healing is desirable in UP and shed light on its potential utility in preventing disease-related complications and improving long-term outcomes.

References

1. Peyrin-Biroulet L, Sandborn W, Sands BE, et al. Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE): Determining Therapeutic Goals for Treat-to-Target. Off J Am Coll Gastroenterol ACG. 2015;110(9):1324-1338. doi:10.1038/ajg.2015.233
2. Colombel JF, Rutgeerts P, Reinisch W, et al. Early Mucosal Healing With Infliximab Is Associated With Improved Long-term Clinical Outcomes in Ulcerative Colitis. Gastroenterology. 2011;141(4):1194-1201. doi:10.1053/j.gastro.2011.06.054
3. Impact of mucosal healing on long‐term outcomes in ulcerative colitis treated with infliximab: a multicenter experience - Laharie - 2013 - Alimentary Pharmacology & Therapeutics - Wiley Online Library. Accessed September 24, 2022. https://onlinelibrary.wiley.com/doi/full/10.1111/apt.12289
4. Zhou Q, Shen ZF, Wu B sheng, et al. Risk of Colorectal Cancer in Ulcerative Colitis Patients: A Systematic Review and Meta-Analysis. Gastroenterol Res Pract. 2019;2019:1-11. doi:10.1155/2019/5363261

Disclosure

E.L., A.A.: no conflicts of interest to disclose
R.B.: Consulting/Speaker: Janssen, Abbvie, Bristol Myers Squibb, Prometheus Laboratories, Pfizer, Takeda
R.L.: Consulting/Speaking Fees: Pfizer, Enzymetrics, Ancilia Biosciences. Grant Support: National Institute of Health (NIH)
E.S.: Consulting/Speaking Fees: AbbVie, Crohn’s and Colitis Foundation of America (CCFA), Entera Health, Evidera, GI Health Foundation, Janssen, Protagonist Therapeutics, Seres Health, Takeda Pharmaceuticals, Bristol Myers Squibb. Grant Support: Abbott (AbbVie), AstraZeneca, CCFA, Janssen Research & Development, Johns Hopkins University, National Institute of Diabetes and Digestive and Kidney (NIDDK), National Institute of Health (NIH), New York Crohn’s Foundation, Pfizer, UCB, UCSF–CCFA Clinical Research Alliance, Genentech, Seres Therapeutics, Celgen. R.B.: Consulting: Prometheus
D.L.: Consulting/Speaking Fees: Abbvie, Boehringer Ingelheim, Eli Lilly, Fresenius Kabi, Janssen, Palatin, Pfizer, Prometheus Biosciences, Takeda; Grants: Abbvie, Janssen, Takeda

Clinical Case Summary

Common variable immunodeficiency (CVID) is the most common symptomatic primary immunodeficiency in clinical practice. These patients have up to 50 times higher risk of developing cancer in comparison to the general population, with gastric adenocarcinoma being the leading cause of death in this population.
We describe a case of a 33-year-old woman with a history of CVID and Addison's disease, who was admitted for upper gastrointestinal hemorrhage with hemodynamic instability refractory to combined endoscopic hemostasis (noradrenaline, hemoclips, thermocoagulation and hemostatic spray) after partial resection of a 40 mm semipediculated gastric polyp (figures 1,2), finally requiring selective arterial embolization to control bleeding. Histological and immunohistochemical studies revealed gastric adenocarcinoma HER2+ with conserved expression of proteins encoded by DNA repair genes.
Multiple studies have demonstrated a dysfunctional immune system at the level of the non-neoplastic gastric mucosa of these patients, characterized by high rates of CD4+, CD8+, Foxp3+, GATA3+, PD-L1 and low numbers of CD20+ B-lymphocytes and CD138+ plasma cells compared to individuals without CVID. In addition, the expression of GATA3+ by cytotoxic T lymphocytes is identified in the literature as a mechanism for tumor escape from immunological surveillance and T-cell depletion. On the other hand, few studies have focused on analyzing the monogenic causes of CVID. This could be an interesting field of study since genes, such as NF-Kb1 deficiency, which is the most common monogenic cause of CVID, have in turn been directly related to the pathogenesis of gastric cancer in individuals without CVID. All this is very important when it comes to being able to stratify our patients according to the risk of developing malignant gastric pathology in order to establish standardized screening recommendations and to be able to carry out individualized follow-ups in order to detect premalignant lesions.

References

Bruns L, Panagiota V, von Hardenberg S, et al. Common Variable Immunodeficiency-Associated Cancers: The Role of Clinical Phenotypes, Immunological and Genetic Factors. Front Immunol. 2022;13:742530. Published 2022 Feb 17.
Pecoraro A, Crescenzi L, Varricchi G, Marone G, Spadaro G. Heterogeneity of Liver Disease in Common Variable Immunodeficiency Disorders. Front Immunol. 2020;11:338. Published 2020 Feb 28. doi:10.3389/fimmu.2020.00338
Pikkarainen S, Martelius T, Ristimäki A, Siitonen S, Seppänen MRJ, Färkkilä M. A High Prevalence of Gastrointestinal Manifestations in Common Variable Immunodeficiency. Am J Gastroenterol. 2019 Apr;114(4):648-655.
Pulvirenti F, Pecoraro A, Cinetto F, et al. Gastric Cancer Is the Leading Cause of Death in Italian Adult Patients With Common Variable Immunodeficiency. Front Immunol. 2018;9:2546. Published 2018 Nov 5.
Gullo I, Costa C, Silva SL, et al. The Dysfunctional Immune System in Common Variable Immunodeficiency Increases the Susceptibility to Gastric Cancer. Cells. 2020;9(6):1498. Published 2020 Jun 19.