Introduction

Crohn's disease (CD) has a segmental distribution and possible involvement of the entire gastrointestinal (GI) tract. Pan-enteric capsule endoscopy (CE) is shown to be a highly sensitive tool for detecting pathology in patients with suspected Crohn's disease. A disadvantage of CE is the time-consuming analysis of the images. Artificial intelligence (AI) algorithms might offer a possibility to assist in the review and reduce the analysis time of CE.

Aims & Methods

This study examines the agreement between pan-enteric CE analyzed by specialists utilizing an AI algorithm to regular CE readings in patients with suspected CD.
Patients and methods: Pan-enteric CE’s from a prospective blinded, multicenter study, including patients suspected of CD (ClinicalTrials.Gov NCT03134586)[1], were anonymized, and videos from the first duodenal- to the last rectal picture were generated using Pillcam Rapid reader v.9 (Medtronic, Dublin, Ireland). Videos were processed by the deep learning solution AXARO® (Augmented Endoscopy, Paris, France), and two GI specialists reviewed images of interest. Based on the image output, the observers classified the patient’s CE as suggestive of CD, ulcerative colitis (UC), cancer, or as having a normal CE. Observers were blinded to patient histories, the results of the complete CE analysis, and the ileocolonoscopy. Previous GI-specialist evaluation of the CE, following standard procedure in the Rapid reader software v9, served as the reference standard. The time used for the AI review was recorded. Per-patient sensitivities, specificities, and positive and negative predictive values for detecting CD and Inflammatory bowel disease (IBD) (CD+UC) were calculated for the two observers, and Cohen’s kappa assessed interobserver agreement. Following the blinded assessment, all disagreement was reviewed.

Results

Pan-enteric CEs from 131 patients were included in this analysis (95 women, 73%) with a median age of 28 years (range 16-72). CE was complete in 109 (83.0%) patients, and the mean CE recording time was 374 minutes.
The AXARO® framework reduced the image output to a median of 2.1%, corresponding to 470 images per patient, and the two observers had a pooled mean review time of 208 seconds per patient. The following results were obtained for Observer 1 and Observer 2, respectively, a sensitivity for detecting CD of 96% and 92% and a specificity of 93% and 90%. IBD was detected with a 97% and 97% sensitivity and specificity of 91% and 90%. The negative predictive value in this cohort was 95% for CD and 97% for IBD. The interobserver agreement was very high, with a kappa of 0.91 (CI 0.82-0.97) and 0.92 (CI 0.85-0.98) for CD and IBD, respectively. A disagreement review showed challenges with very mild disease and correctly classifying inflammation. The number of false positives was mainly due to non-specific inflammation, which did not meet the diagnostic criteria for CD in the reference standard evaluation. Two cancers were correctly detected, but a single adenomatous polyp was not detected.

Conclusion

Using the AXARO® framework to select pictures of interest reduced the initial review time to a median of less the four minutes while maintaining high diagnostic accuracy. The interobserver agreement was very high, and disagreement occurred in very mild cases or classifications of inflammation. The high sensitivity and negative predictive value show that this AI algorithm could be used as a rapid tool to ”rule out” IBD in pan-enteric CEs of newly referred patients suspected of Crohn’s disease.

References

1. Brodersen JB, Knudsen T, Kjeldsen J et al. Diagnostic accuracy of pan-enteric capsule endoscopy and magnetic resonance enterocolonography in suspected Crohn's disease. United European gastroenterology journal 2022. DOI: 10.1002/ueg2.12307

Disclosure

JBB, MDJ, JK, and TK have nothing to disclose
RL: Co-founder and shareholder of Augmented Endoscopy
AH: Co-founder and shareholder of Augmented Endoscopy
XD: Co-founder and shareholder of Augmented Endoscopy; Consultancy for Norgine and Provepharma; Lecture fees for Alfasigma, Bouchara Recordati, Medtronic, Norgine, Sandoz, Fujifilm

Introduction

The treatment outcomes and risk factors for the prognosis of acute variceal bleeding (AVB) in hepatocellular carcinoma (HCC) patients remain unclear. Hence, we assessed the clinical outcomes and prognostic factors of these patients.

Aims & Methods

To evaluate the treatment outcomes and risk factors of cirrhotic patients with hepatocellular carcinoma (HCC) and acute variceal bleeding (AVB).
This is a retrospective case-control study. Consecutive patients with HCC and AVB admitted between 2016 and 2022 were included. For each patient with HCC, a patient without HCC was matched by age, sex, and Child-Pugh class. Follow-up was continued until death and transplantation.

Results

A total of 620 patients were included. The five-day treatment failure and 6-week mortality rates of the whole cohort were 18.7% and 16.6%, respectively. Patients with HCC had higher 6-week mortality, respectively (24.2% vs. 9.0%, P<0.001). Among AVB patients with HCC, the Barcelona Clinic Liver Cancer (BCLC) stage (C-D vs. 0-B) (HR, 14.409; 95% CI, 5.758-36.055; P<0.001), and Child-Pugh score (HR, 1.239, 95% CI, 1.121-1.370; P<0.001) were independent risk factors of 6-week mortality in multivariate analysis. Furthermore, the risk of 6-week mortality was 60.2% among patients with a Child-Pugh score ≥ 9 and BCLC stage C–D, much higher than patients with low Child-Pugh score (<9) and earlier BCLC stage (0-B) (P<0.0001).

Conclusion

Among patients with cirrhosis and AVB, patients with HCC had a worse outcome than patients without. The severity of liver disease and the stage of HCC are the main determinants of mortality in HCC patients.

Introduction

The global health community has increasingly shifted its focus toward non-communicable diseases (NCDs), recognizing them as a critical public health emergency, particularly pronounced in low and lower middle-income countries (LMICs)[1]. Metabolic dysfunction associated steatotic liver disease (MASLD) is the most common liver disease with a worldwide prevalence of 30%[2], and represent the leading cause of liver-related morbidity and mortality. The prevalence, associated factors, and consequences of MASLD in the African continent, particularly in SSA, remain poorly understood. Indeed, no SSA studies were included in the latest major literature review and meta-analysis on the global epidemiology of MASLD[2].
Tanzania, like many other SSA countries, is undergoing a demographic and epidemiological transition, leading to a marked increase in the burden of NCDs [3].

Aims & Methods

The primary aim of this study was to estimate the prevalence of MASLD among an NCDs population in rural Tanzania. Additionally, secondary objective was to investigate whether the consumption of sugary drinks is associated with MASLD.
This study entailed a retrospective analysis of a prospectively collected cohort of consecutive patients attending the NCDs outpatient clinic of Tosamaganga Hospital, from August 2022 to March 2023. Detailed sociodemographic, clinical, laboratory, and abdominal ultrasound data were collected for all participants. Additionally, the Beverage Intake Questionnaire (BEVQ-15) was administered to evaluate their everyday drinking behaviors; and for each item, the average daily intake in fluid ounces (fl-oz), and calories (kcal) were calculated.

Results

Of 183 patients enrolled in the cohort, 128/183 (70%) were female. The mean age was 58±13.7 years and mean BMI was 28±6.67 Kg/m². Hypertension affected 141 individuals (77.0%), diabetes affected 77 (42.1%), and both conditions co-occurred in 35 patients (19.1%). Steatotic liver disease was found in 88/183 (48%) patients; with 39/88 (44.3%) of moderate or severe steatosis. MASLD was identified in all steatotic patients. Overall, on average the participants drank a mean of 12.6 fl-oz of SSB (throght sodas). MASLD patients drank an average of 22.4 fl-oz of SSB per day. Multivariable analysis revealed that BMI and daily SSB consumption (fl-oz) exhibited significant associations with MASLD, with respective OR of 1.16 (95% CI: 1.06 – 1.28, p = 0.002) and 1.19 (95% CI: 1.12 – 1.27, p < 0.001).

Conclusion

This study unveils a considerable prevalence of MASLD among the rural Tanzanian NCDs population, affecting nearly half (48%) of all patients studied. Timely identification of MASLD, facilitated by straightforward diagnostic means, holds pivotal importance for patient management and the dissemination of vital lifestyle modification guidance. Furthermore, our study, one of the pioneering efforts to demonstrate a significant association between SSB consumption and MASLD in an African context, underscores the imperative to heighten awareness regarding the risks posed by SSB consumption among NCDs patients and potentially the wider population.

References

[1] Boutayeb A. The Burden of Communicable and Non-Communicable Diseases in Developing Countries. Handbook of Disease Burdens and Quality of Life Measures 2010:531–46. https://doi.org/10.1007/978-0-387-78665-0_32.
[2] Younossi ZM, Golabi P, Paik JM, Henry A, Van Dongen C, Henry L. The global epidemiology of nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH): a systematic review. Hepatology 2023;77:1335–47. https://doi.org/10.1097/HEP.0000000000000004.
[3] Gouda HN, Charlson F, Sorsdahl K, Ahmadzada S, Ferrari AJ, Erskine H, et al. Burden of non-communicable diseases in sub-Saharan Africa, 1990-2017: results from the Global Burden of Disease Study 2017. Lancet Glob Health 2019;7:e1375–87. https://doi.org/10.1016/S2214-109X(19)30374-2.

Introduction

Colorectal cancer incidence is increasing worldwide. Nowadays it is the third most diagnosed cancer¹. Screening colonoscopy is the gold standard for prevention and often treatment, both economically and efficiently. Hellenic Society of Gastroenterology recommends that screening colonoscopy should starts by 50 years old for average risk population¹. There are limited data about participation in screening colonoscopy in general population in Greece and the existing ones shows discouraging participation rates^2,3.

Aims & Methods

The aim of this study was to determinate general population’s knowledge about screening colonoscopy in Greece. We created a digital, anonymous questionnaire at Google Forms platform and transferred it via social media in general population that lives in Greece.

Results

In total 711 individuals answered the survey. 65.8% of them(468/711) were woman. 61.5% (437/711) were under 40 years old, 19.7% (140/711) were between 40 and 50 years old and 18.3% (130/711) were between 50 and 75 years old. 40.2% (286/711) did not know if there is an appropriate age for the first screening colonoscopy. 39% (277/711) answered that they thought an appropriate age is at 50 years old, 26.7% (190/711) at 45 years old and 8.2% (58/711) answered that they thought there is not an appropriate age for a screening colonoscopy. Regarding the performance of screening colonoscopy 363 out of 711 (51.1%) are willing to perform it in the future, 20.1% (143/711) answered that they do not know or do not answer the question,11% (78/711) are not willing to perform it and 2.1% (15/711) are not willing to perform it, because they think it is not necessary for preventing colorectal cancer.

Conclusion

Our study confirms that there is lack of information in general population and unwillingness to screen for colorectal cancer in Greece. General population tends to be uninformed and unwilling about screening colonoscopy¹. Despite the effectiveness of colonoscopy there is not an organized screening program in Greece. Individuals are usually self-referred for screening and usually later than the appropriate age and after symptoms occure¹. Primary health care providers should be well informed and correctly advise individuals about colorectal cancer screening and its privilege, options, and alarm symptoms⁴.

References

1. Viazis N, Tzouvala M, Theodoropoulou A, Giouleme O, Thomopoulos K, Christodoulou DK, Michopoulos S, Soufleris K, Koutroubakis I, Karamanolis G, Papatheodoridis G, Giotis I, Paspatis G, Mantzaris GJ. Comparison of the Uptake of Screening Colonoscopy between Physicians and the General Population in Greece. Dig Dis. 2020;38(1):23-30. doi: 10.1159/000501266. Epub 2019 Jul 9. PMID: 31288225.
2. Kamposioras K, Mauri D, Golfinopoulos V, Ferentinos G, Zacharias G, Xilomenos A, Polyzos NP, Bristianou M, Chasioti D, Milousis A, Vittoraki A, Koukourakis G, Chatziioannou I, Papadopoulos P. Colorectal cancer screening coverage in Greece. PACMeR 02.01 study collaboration. Int J Colorectal Dis. 2007 May;22(5):475-81. doi: 10.1007/s00384-006-0186-6. Epub 2006 Aug 29. PMID: 16941174.
3. Cardoso R, Guo F, Heisser T, Hoffmeister M, Brenner H. Utilisation of Colorectal Cancer Screening Tests in European Countries by Type of Screening Offer: Results from the European Health Interview Survey. Cancers (Basel). 2020 May 29;12(6):1409. doi: 10.3390/cancers12061409. PMID: 32486077; PMCID: PMC7352919.
4. Mastrokostas A, Gavana M, Gkrizioti M, Smyrnakis E, Cholongitas E, Benos A, Haidich AB. Discrepancies and misconceptions of perceived colorectal cancer screening barriers between primary health professionals and unscreened population. A comparative study in Greece. J BUON. 2018 Dec;23(7):67-76. PMID: 30722114.

Introduction

Numerous studies suggested a pivotal role of gut microbiota and its metabolites in the development and progression of metabolic-associated steatotic liver disease (MASLD) [1]. So, modification of the gut microbiota and/or the metabolites could be beneficial in children with MASLD [2].

Aims & Methods

The aim of our study was to determine the gut microbiome composition in obese children with metabolic-associated steatotic liver disease (MASLD) depending on the contractile function of the gallbladder.
A survey included 73 children aged 10 to 17 years (mean age – 12.15 ± 2.51 years). According to body mass index, transient elastography (Fibroscan®502 touch, Echosens, France), and ultrasound data patients were divided into 3 groups: 1 group – 35 obese MASLD children with gallbladder hypokinesia, 2 group – 30 obese MASLD children with gallbladder normokinesia, 3 group (control) – 8 healthy children with normal weight and gallbladder normokinesia. Contractile gallbladder function was assessed by ultrasound examination after physiological nutritional load. Qualitative and quantitative intestinal microbiome composition were investigated by bacterial culture method using ten-fold dilutions (10^-1 - 10^-9) on a standard set of selective and differential diagnostic culture media for the aerobic and anaerobic microbes isolation. Fecal short-chain fatty acid (SCFA) content was evaluated with gas chromatography (Chromatec-Crystal-5000).

Results

An increase in the fecal butyric acid concentration in 2.0 times (p<0.05) was observed in MASLD children with gallbladder hypokinesia compared to the control group. Also, an increase in the fecal acetic acid concentration in 6.9 times (p<0.05) in 1 group children and in 6.8 times (p<0.01) in 2 group children was found compared to the control group. However, a significant decrease in the fecal propionic acid content in 2.4 times (p<0.001) in MASLD children with gallbladder hypokinesia and in 3.6 times (p<0.001) in MASLD children with gallbladder normokinesia was revealed compared to the control group. Due to the increased content of fecal acetic and butyric acids, the total content of SCFA (Σ (C2-C4)) was increased in 2.3 times in 1 group children compared to the control group (p<0.05).
Patients with decompensated dysbiosis predominated in 1 group children (37.1% of patients). In 2 group children the subcompensated dysbiosis was more common (36.7% of patients). The concentration of Lactobacillus and Enterococcus in 1 group patients was significantly lower than in 2 group patients: in 1.9 times (p<0.05) and in 1.4 times (p<0.05), respectively.

Conclusion

Impaired contractile function of the gallbladder in MASLD children is associated with a sharp decrease in the number of major symbionts of the intestinal microbiota as well as increased production of fecal acetic and butyric SCFA.

References

1. Effenberger M, Grander C, Grabherr F, Tilg H. Nonalcoholic Fatty Liver Disease and the Intestinal Microbiome: An Inseparable Link. J Clin Transl Hepatol. 2023;11(7):1498-1507. doi:10.14218/JCTH.2023.00069.
2. Bonsembiante L, Targher G, Maffeis C. Non-alcoholic fatty liver disease in obese children and adolescents: a role for nutrition?. Eur J Clin Nutr. 2022;76(1):28-39. doi:10.1038/s41430-021-00928-z

Introduction

Capsule endoscopy (CE) is commonly used as the initial exam in situations of suspected mid-gastrointestinal bleeding, after normal upper and lower endoscopy. Although the assessment of the small bowel is the primary focus of CE, detection of upstream or downstream vascular lesions may also be clinically significant. This study aimed to develop and test a Convolutional Neural Network (CNN)-based model for panendoscopic automatic detection of vascular lesions during CE.

Aims & Methods

A multicentric retrospective study was conducted, based on 1022 CE exams. We used a total of 35655 frames, from seven types of CE devices (PillCam Colon 1, PillCam Crohn's, PillCam SB1, PillCam SB3, OMOM HD, Olympus, Mirocam), of which 11091 were considered to have vascular lesions (angiectasia or varices) after triple validation. We divided data into a training and a validation set, the latter being used to evaluate the model’s performance. At time of division, all frames from a given patient were assigned to the same dataset. Our primary outcome measures were sensitivity, specificity, accuracy, positive predictive value (PPV), negative predictive value (NPV) and an area under the precision-recall curve (AUC-PR).

Results

A total of 35655 frames were used, with 11091 including vascular lesions. The validation data set contained 2433 frames with normal mucosa and 933 vascular lesions.
Sensitivity and specificity were 86.4% and 98.3%, respectively. PPV was 95.2%, while the NPV was 95.0%. Overall accuracy was 95.0%. The AUC-PR value was 0.96. The CNN processed 115 frames per second.

Conclusion

The study presents promising results for the application of AI deep learning models in panendoscopic automatic detection of vascular lesions in various gastrointestinal topographies. The methodological details, including the patient-split design and the use of frames from different types of CE devices, suggest that the model could be effectively used in routine clinical practice independently of the device brand. This study highlights the potential of panendoscopic evaluation of all gastrointestinal tract and the need for further research in this area. Overall, the high diagnostic performance of this CNN in multibrand devices addresses an important issue of technological interoperability, allowing it to be replicated in multiple technological settings. However, the study has some limitations, including a small number of frames and a retrospective design, which may introduce selection bias, therefore prospective and multicentric studies are needed before introducing this deep learning model into clinical practice. This is the first proof-of concept AI deep learning model developed for panendoscopic automatic detection of vascular lesions during CE.

References

Triester, S.L., et al., A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with obscure gastrointestinal bleeding. Am J Gastroenterol, 2005. 100(11): p. 2407-18.
Liao, Z., et al., Indications and detection, completion, and retention rates of small-bowel capsule endoscopy: a systematic review. Gastrointest Endosc, 2010. 71(2): p. 280-6.
Rondonotti, E., et al., Small-bowel capsule endoscopy and device-assisted enteroscopy for diagnosis and treatment of small-bowel disorders: European Society of Gastrointestinal Endoscopy (ESGE) Technical Review. Endoscopy, 2018. 50(4): p. 423-446.
Ribeiro, T.F.-U.I.C.H., Colon capsule endoscopy and artificial intelligence: a perfect match por panendoscopy, in Artificial Intelligence in Capsule Endoscopy, C.H. Mascarenhas M, Macedo G, Editor. 2023, Academic Press.
Tsuboi, A., et al., Artificial intelligence using a convolutional neural network for automatic detection of small-bowel angioectasia in capsule endoscopy images. Dig Endosc, 2020. 32(3): p. 382-390.
Saurin, J.C., et al., Diagnostic value of endoscopic capsule in patients with obscure digestive bleeding: blinded comparison with video push-enteroscopy. Endoscopy, 2003. 35(7): p. 576-84.
Mascarenhas, M., et al., Deep learning and colon capsule endoscopy: automatic detection of blood and colonic mucosal lesions using a convolutional neural network. Endosc Int Open, 2022. 10(2): p. E171-e177

Introduction

The incidence and severity of metabolic dysfunction-associated steatotic liver disease (MASLD) are notably higher in individuals diagnosed with type 2 diabetes mellitus (T2DM). However, studies evaluating the progression of MASLD in patients with T2DM and normal serum aminotransferase (ALT) levels are limited.

Aims & Methods

This 5-year prospective cohort study aimed to evaluate the progression of MASLD in T2DM patients with normal ALT. People with type 2 diabetes who had MASLD (defined by controlled attenuation parameter (CAP) >250 dB/min) and ALT levels that stayed normal (defined by ALT ≤40 IU/L for at least two occasions spanning at least six months) at Rajavithi Hospital, Bangkok, from November 2016 to 2017 were included. We excluded patients with viral hepatitis and alcohol consumption exceeding moderate levels. Transient elastography (TE) and CAP measurements were performed at baseline and ≥5 years of follow-up. The cutoffs to define significant and advanced fibrosis were TE >8 kPa and TE >12 kPa, respectively. All patients were instructed to reduce their weight and abstain from herbal remedies; medications for comorbidities were prescribed without limitations, subject to the physician's assessment. (most patients were under endocrinologist care.)

Results

The study included 84 patients, 57% of whom were female and had a mean age of 58.5 years. Of these, 62% were obese, with a mean BMI of 28.6 kg/m2. At baseline, the median TE was 6.92±3.35 kPa; 57 (68%) had no significant fibrosis, 22 (26%) had significant fibrosis, and 5 (6%) had advanced fibrosis, and after a 5-year follow-up, the median TE was 6.54±3.57 kPa; 69 (82%) had no significant fibrosis, 15 (18%) had significant fibrosis, and 2 (2%) had advanced fibrosis. During the follow-up, fibrosis decreased in 45 (54%), remained stable in 6 (7%), and increased in 33 (39%) patients, while a small proportion of patients experienced changes in the stages of fibrosis: 1.2% progressed from significant to advanced fibrosis; 17.4% regressed from advanced to significant fibrosis or transitioned from significant to no fibrosis; 12.8% remained stable with significant and advanced fibrosis; and the majority (66.3%) remained without significant fibrosis. A significant factor associated with fibrosis progression was alcohol consumption (p=0.013), while the use of angiotensin receptor blockers (p=0.042) was associated with fibrosis regression. Significant factors associated with steatosis progression included high baseline BMI (p=0.013), an increase in BMI ≥ 5% (p=0.04), high fasting plasma glucose, and LDL cholesterol levels, while a decrease in BMI ≥ 5% (p=0.002) the use of calcium channel blockers (p=0.038) and coffee consumption >3 cups per day (p=0.031) were associated with steatosis regression. ALT elevation during the follow-up occurred in a small proportion of patients, and it was not significantly associated with fibrosis or steatosis progression.

Conclusion

The majority of MASLD patients with T2DM and normal ALT maintained a relatively stable liver disease during 5 years of follow-up. Obesity, weight gain, alcohol consumption, and inadequate metabolic control were all associated with the progression of MASLD, whereas weight loss, coffee consumption, angiotensin receptor blockers, and calcium channel blockers were all associated with the improvement of MASLD.

Disclosure

I have nothing to disclose