Introduction

Various endoscopic closure procedures including over-the-scope systems and endoscopic hand suturing have been tested in preventing delayed bleeding after endoscopic resection1). Conventional procedures are technically difficult with long procedure time1), which partially explains its limited application in clinical practice. The novel through-the-scope (TTS) helix and tack suture system has been reported with high success rates and acceptable procedure time using in vivo porcine models along with clinical experience2,3). However, past reports have not identified the proficiency rate of the TTS suture system.

Aims & Methods

The objective of this study is to determine the number of cases needed in achieving closure time of literature-based mean closure time. One beginner with less than 400 experiences of upper gastrointestinal endoscopy and one expert with clinical experience of over 500 endoscopic submucosal dissections participated in this study. Both endoscopists were familiarized with the functionality and troubleshooting of the novel TTS suture system via educational videos. Four in vivo porcine models were used to create 24 mucosal defects with diameter of 2-4 cm in the stomach. Each endoscopist were randomly allocated 12 mucosal defects to close with one set of TTS suture system per procedure. The TTS suture system engages four 5 mm helical tacks tethered to a suture thread into the defect margin and approximates the mucosal defect by applying suture tension with a cinch. The primary outcome was the number of procedures required to achieve closure procedure time below the literature-based mean closure time (7.7 minutes) by inverse curve fitting with nonlinear regression. The secondary outcomes were the success rate of complete closure and the incidence of adverse events. Complete closure was defined as over 90% closure of defect in endoscopy image assessed by two certified endoscopy technicians.

Results

Mean (±SD) size of the mucosal defects was 2.9 (±0.2) cm. Both endoscopists required six cases to achieve a closure time of less than 7.7 minutes. The median closure time was 8.2 (IQR: 5.6-10.1) minutes for the expert and 8.0 (IQR: 6.3-9.4) minutes for the beginner (P = 0.8624). The success rates of complete closure were 75.0% (9/12) for the expert and 83.3% (10/12) for the beginner. Neither endoscopist experienced any adverse events.

Conclusion

The novel TTS suture system requires a small number of cases for both expert and beginner to achieve proficiency in endoscopic closure.

References

1) Kobara H, et al. Dig Endosc. 2023;35(2):216-31.
2) Hernandez A, et al. Endosc Int Open. 2021;09:E572-7.
3) Farha J, et al. Endoscopy. Published online: 12 Jan 2023; doi:10.1055/a-1970-5528.

Introduction

Steatotic liver disease (SLD) encompasses a spectrum of conditions, including metabolic dysfunction-associated SLD (MASLD), alcohol-related liver disease (ALD), and the overlapping category of MetALD. SLD affects more than a third of adults globally, but the majority remain undiagnosed, partially due to its lack of symptoms and limited awareness among patients and physicians. Adults undergoing screening colonoscopy, typically aged ≥50 years, represent a key population for targeted SLD detection, as they have a higher prevalence of cardiometabolic risk factors and is already engaged with preventive healthcare.

Aims & Methods

We examined 610 consecutive individuals aged ≥50 years with no known history of chronic liver disease who were referred for a colonoscopy for colorectal cancer screening. The protocol included sonographic assessment of liver steatosis and point shear wave elastography (pSWE) for liver fibrosis quantification, anthropometric measurements, biochemistry, medical history and alcohol intake evaluation. From the collected data, non-invasive fibrosis scores were calculated and used for aetiological and risk stratification.

Results

A total of 543 patients were included in the final analysis, after excluding patients with an invalid pSWE measurement (5.3%, n=29) and then excluding patients with incomplete results (n=38). The median age was 64 years (IQR 57-70) and 54.0% were male. The median BMI was 28.7 kg/m² (IQR 25.8–31.4) in males and 28.3 kg/m² (IQR 24.2-31.5) in females. SLD was identified in 63.4 % (n=344) of participants. Elevated liver stiffness (pSWE ≥ 1.30 m/s) was found in 26.9 % (n=146), and 4.8% (n=26) had values ≥1.70 m/s, suggestive of compensated advanced chronic liver disease. Among patients with pSWE ≥ 1.30 m/s, MASLD was the predominant aetiology (69.9%, n=102), followed by MetALD (15.8%, n=23), ALD (1.4%, n=2), cryptogenic (11.6%, n=17) and other etiologies (1.4%, n=2). Preselection using EASL-EASD-EASO criteria (i.e. presence of type 2 diabetes or central obesity plus ≥1 cardiometabolic risk factor and elevated liver enzymes) would have detected 365 at-risk individuals (67.2% of the cohort) of whom 55.9% (n=204) had a FIB-4 index ≥1.30. This approach would have identified only 30.4% (n=38) of all the patients with MASLD/MetALD with elevated liver stiffness (n=125).

Conclusion

Opportunistic screening for SLD in patients undergoing screening colonoscopy could be a useful strategy for detecting asymptomatic and potentially progressive liver disease. This approach identified a high prevalence of SLD (63.4%) and elevated liver stiffness (26.9%) in this population, primarily due to MASLD and MetALD. The integration of ultrasound and elastography added minimal burden to the existing workflow while enabling early risk stratification without the need for additional patient visits or referrals.

References

1 Tacke F, Horn P, Wong VWS, Ratziu V, Bugianesi E, Francque S, et al. EASL–EASD–EASO Clinical Practice Guidelines on the management of metabolic dysfunction-associated steatotic liver disease (MASLD). Journal of Hepatology [Internet]. 2024 Jun 7;81(3):492–542.
2 Lazarus JV, Miralles-Sanchez JE, Agirre-Garrido L, Brachowicz N, Nicolàs A, Armenta A, et al. A call to action to address the steatotic liver disease public health threat in Barcelona. The Lancet Regional Health - Europe [Internet]. 2025 Mar 22;52:101272.
3 Barr RG, Wilson SR, Rubens D, Garcia-Tsao G, Ferraioli G. Update to the Society of Radiologists in Ultrasound Liver Elastography Consensus Statement. Radiology [Internet]. 2020 Jun 9;296(2):263–74.

Clinical Case Summary

A 47-year-old female with a one-year history of ulcerative colitis (UC) presented with painful red skin lesions on her wrists and anterior tibiae, which progressed to necrotic ulcers (1). Initial treatment for her UC was mesalamine; however, she experienced three steroid-dependent flares. Prior to the initiation of infliximab for luminal disease activity, these progressive necrotic ulcers developed. Physical examination revealed deep, irregularly bordered, necrotic-based ulcerative lesions with erythematous rims. Bilateral pulses were palpable, and mucous membranes were normal. There was no history of animal exposure or recent travel. Elevated C-reactive protein (9 mg/L, ref: 0-5 mg/L) and negative procalcitonin were noted; other tests, including rheumatoid factor, antinuclear antibody, antineutrophil cytoplasmic antibody, viral serology, and deep tissue cultures for microorganisms, were unremarkable. A skin biopsy demonstrated a necrotic epidermis and neutrophilic infiltrates, consistent with suspected pyoderma gangrenosum, which was supported by a colonoscopy showing Mayo 3 active UC. The tuberculin skin test was negative. Infliximab was initiated, resulting in an intestinal response but only a partial response of the skin lesions (2). Topical tacrolimus ointment was added. Following the infliximab induction regimen, limited improvement in the skin lesions prompted the addition of systemic corticosteroids. After two weeks, a partial response persisted, and prednisolone was tapered. Infliximab was discontinued, and ustekinumab therapy combined with hyperbaric oxygen therapy was initiated, leading to significant regression of the skin lesions starting from the tenth day (3). This case illustrates refractory pyoderma gangrenosum in ulcerative colitis with a limited response to initial anti-tumor necrosis factor therapy, highlighting the potential of interleukin-23 pathway inhibition for managing this extra-intestinal manifestation.

References

References of illustrative material:
1. Clinical Photograph of Initial Wrist Lesions: Demonstrates the early presentation of pyoderma gangrenosum as erythematous and painful lesions on the patient's wrists upon initial presentation.
2. Clinical Photograph of Refractory Tibial Ulcers: Shows the characteristic deep, necrotic, and irregularly bordered ulcers on the patient's anterior tibiae, highlighting the severity and refractory nature of the pyoderma gangrenosum despite initial treatment.
3. Clinical Photograph of Post-Treatment Improvement: Illustrates the significant regression of the skin ulcers on the patient's tibiae following the initiation of ustekinumab and hyperbaric oxygen therapy, demonstrating the positive outcome of the alternative treatment strategy.

Introduction

Clostridioides difficile infection (CDI) is among of the most common causes of nosocomial diarrhea with high morbidity and mortality. Recurrent and refractory disease courses in particular represent a special challenge in the management of these patients. The identification of patients at risk for recurrent courses could improve management, e.g. through the use of new and effective therapies in patients with CDI.

Aims & Methods

The aim of this study was to investigate the relationship between the presence of different comorbidities and the course of CDI.
In a retrospective, monocentric cohort study of a tertiary centre over a period of 10 years, patients with CDI-related hospitalizations were examined. The study included 336 patients with available information on comorbidities (diverticulosis, biliary diseases (cholecysto-, docholithiasis, cholecystitis, cholangitis or cholangiectasis) inflammatory bowel diseases (IBD), liver cirrhosis and malignancies) and the diagnosis of the recurrent CDI (rCDI) vs. non-recurrent course of CDI (nrCDI). Patients on dialysis or immunosuppressed patients were also considered as comorbid.

Results

Among 336 patients included in the study, 227 (67.6%) presented with at least one comorbidity. The most common were malignancy (30.4%), biliary diseases (19.4%), diverticulosis (15.8%), liver cirrhosis (14.3%), and inflammatory bowel disease (IBD, 8.9%). rCDI occurred more frequently in patients with diverticulosis and biliary disease. Diverticulosis was present in 24.4% of rCDI cases vs. 12.6% in nrCDI cases (OR 2.24, 95% CI 1.22–4.17). Biliary diseases were observed in 26.7% of rCDI vs. 16.7% of nrCDI patients (OR 1.82, 95% CI 1.01–3.26). No significant associations with rCDI were found for IBD (OR 0.66, 95% CI 0.27–1.65), malignancy (OR 1.13, 95% CI 0.67–1.88), or liver cirrhosis (OR 0.79, 95% CI 0.38–1.61).

Conclusion

These findings suggest diverticulosis and biliary disease may be independent risk factors for rCDI, whereas other common comorbidities are not significantly associated with recurrence. Structured assessment of risk conditions may help to select patients for tailored management to prevent rCDI disease course.

Introduction

Delayed bleeding (DB) is a possible adverse event following gastric endoscopic submucosal dissection (ESD). The Bleeding after ESD Trend from Japan (BEST-J) score was created as a risk prediction model for DB following gastric ESD, but is yet to be validated in non-Asiatic populations.

Aims & Methods

We aimed to apply and validate the BEST-J score on a European sample.
We have conducted a longitudinal study of all consecutive patients undergoing gastric ESD on a European Endoscopic Unit. DB was defined as a hemorrhage with clinical symptoms and confirmed by emergency endoscopy from the time of completion of ESD to 28 days after ESD.
BEST-J score (use of vitamin K antagonists +4, direct oral anticoagulants +4, aspirin or P2Y12R antagonists +2; withdrawing antithrombotic drugs -1; chronic kidney disease +3; multiple lesions +1; lesion ≥30mm +1; lesion in lower-third of the stomach +1) was calculated in each patient and confronted with the outcome (DB).

Results

Final sample included 161 patients, 102 (63.4%) male, with a mean age of 68±8 years. From these, 10 (6.2%) presented DB following ESD, with a median time to bleeding of 7 days (IQR 6.8).
According to BEST-J score, bleeding risk was low (0-1 points) in 111 (68.9%), intermediate (2 points) in 29 (18.0%), high (3-4 points) in 16 (9.9%) and very high (≥5 points) in 5 (3.1%) patients.
BEST-J score presented an excellent accuracy predicting DB in our sample, with an AUC=0.907 (95%CI=0.801-1.000; p<0.001). The optimal cut-off value to predict DB was a BEST-J score ≥3, which matches the cut-off value for high-risk of bleeding in the original investigation. This value had a sensitivity of 90% and specificity of 92%.

Conclusion

The BEST-J score still presents excellent accuracy in risk stratification for post-ESD bleeding in European individuals. Thus, this score may help to guide which patients benefit the most from prophylactic therapies following gastric ESD in this setting.

Introduction

Endoscopy is essential for the early detection and management of upper gastrointestinal (UGI) tumors, yet variability in diagnostic expertise and workload-related fatigue often compromise the quality of report documentation. These challenges underscore the urgent need for innovative technological approaches to assist endoscopists in optimizing the report generation process.
Multimodal large language models (MLLMs) enable the synergistic integration of visual and semantic representations, demonstrating significant clinical value in medical text generation. This study introduces MERGS, an innovative endoscopy report generation system powered by MLLM. MERGS annotates medical terminology and generates natural language descriptions based on endoscopic images, ultimately producing structured reports that conform to clinical standards.

Aims & Methods

MERGS is built on the pre-trained MLLM Qwen-VL-2.5-7B. It adopts a multimodal architecture integrating visual encoding and cross-modal alignment to enable medical term annotation and natural language generation from endoscopic images. A pathological classification module further enhances lesion characterization. The language model synthesizes image-derived descriptions to generate a comprehensive report with a diagnostic conclusion.
UGI endoscopy reports were collected from the Sun Yat-sen University Cancer Center between 2019 and 2021. A standardized terminology dictionary was developed based on clinical guidelines, supporting a three-tier annotation framework: endoscopic image → standardized medical terminology → natural language text. Model-assisted pre-annotation combined with expert validation substantially reduced manual effort. The resulting dataset was split into training and test sets at an 8:2 ratio.
Model performance was assessed via multi-label classification metrics (accuracy, specificity, F1-score), as well as semantic similarity measures (Jaccard index) to evaluate its ability to recognize anatomical sites and endoscopic features. Natural language generation quality was assessed using BLEU-2 and ROUGE-L scores, and expert satisfaction ratings were collected for 100 randomly sampled outputs to assess readability and clinical relevance. A human–AI comparison was conducted on 50 test reports, comparing system-generated outputs with those authored by experienced endoscopists.

Results

A multimodal dataset was constructed after quality control, comprising 22,373 reports and 135,503 associated images from 21,619 patients. Internal validation demonstrated that MERGS achieved robust performance in automated image interpretation, with 97.3% accuracy and 98.6% specificity for standard anatomical site recognition. In feature identification, it showed high clinical relevance (F1 scores: smooth mucosa 0.915, polyp 0.857, tumor 0.878, erythematous mucosa 0.766).
Generated reports showed strong alignment with reference reports (BLEU-2 = 0.587, ROUGE-L = 0.661) and received high expert satisfaction ratings (mean score: 4.34 ± 0.63 on a 5-point scale). In a human–AI comparison, MERGS-generated reports were considered non-inferior to those authored by endoscopists (scores: MERGS 4.52 ± 0.81 vs. manual 4.68 ± 0.72), with the upper limit of the one-sided 95% CI (0.37) below the non-inferiority margin (0.5, p = 0.0045).

Conclusion

This study developed an automated system for UGI endoscopy reporting powered by an MLLM. Both internal and clinical validation demonstrated the system's high performance in endoscopic image feature recognition and report generation, underscoring its strong potential for clinical deployment.

References

Luo H, Xu G, Li C, He L, Luo L, Wang Z, Jing B, Deng Y, Jin Y, Li Y, Li B, Tan W, He C, Seeruttun S R, Wu Q, Huang J, Huang D W, Chen B, Lin S B, Chen Q M, Yuan C M, Chen H X, Pu H Y, Zhou F, He Y, Xu R H. Real-time artificial intelligence for detection of upper gastrointestinal cancer by endoscopy: a multicentre, case-control, diagnostic study[J]. Lancet Oncol, 2019,20(12):1645-1654.