Introduction

Over the past decade, endoscopic retrograde appendicitis therapy (ERAT) has emerged as a novel, minimally invasive treatment option for patients with acute uncomplicated appendicitis (AUA). However, it is not yet known whether ERAT is a feasible alternative to antibiotic therapy (ABT).

Aims & Methods

This study aims to evaluate the efficacy of ERAT versus ABT in patients with AUA. We performed a systematic review across PubMed, Embase, and Cochrane CENTRAL databases, searching for studies comparing ERAT to ABT in this population. Outcomes of interest included therapeutic success, — defined as the absence of reintervention up to 1 year of follow-up — recurrence rates, mean time to disease recurrence, and length of hospital stay (LOS). Risk ratios (RR) were used to evaluate binary outcomes with their corresponding 95% confidence intervals (CI), while the mean difference (MD) was calculated for continuous outcomes. All statistical analyses were performed using R software (version 4.4.1) with a random-effects model.

Results

This meta-analysis included 3 studies — 2 control-matched cohorts and 1 randomized trial — comparing 457 ERAT patients to 784 patients receiving ABT for AUA. Baseline clinical characteristics were equally distributed between the groups and the time of follow-up ranged from 3 to 12 months. There was no statistically significant difference between ERAT and ABT in treatment success (RR 1.06; 95% CI 1.00 to 1.12; p = 0.07) or recurrence rate (RR 0.36; 95% CI 0.11 to 1.22; p = 0.10). The difference in time to recurrence was also not significant (MD 116 days; 95% CI -49 to 282; p = 0.17). However, ERAT was associated with a significantly shorter LOS (MD -1.85 days; 95% CI -3.15 to -0.55; p = 0.005).

Conclusion

In patients with acute uncomplicated appendicitis, ERAT is non-inferior to antibiotic therapy, while considerably reducing the length of hospital stay. Further studies are warranted to better assess the efficacy of ERAT compared to ABT, and whether it decreases the risk of appendicitis recurrence.

References

1. Kang, J., et al. (2021). The modified endoscopic retrograde appendicitis therapy versus antibiotic therapy alone for acute uncomplicated appendicitis in children. Surgical Endoscopy, 35(11), pp.6291-6299. Available at: https://doi.org/10.1007/s00464-020-08129-8.
2. Li, D., et al. (2023). Endoscopic retrograde appendicitis therapy or antibiotics for uncomplicated appendicitis. British Journal of Surgery, 110(6), pp.635-637. Available at: https://doi.org/10.1093/bjs/znad023.
3. Zhan, K., et al. (2024). Visual Endoscopic Retrograde Appendicitis Therapy Vs Antibiotic Therapy for Treatment of Uncomplicated Acute Appendicitis. The American Journal of Gastroenterology. Available at: https://doi.org/10.14309/ajg.0000000000003118.
   

Clinical Case Summary

Introduction: Intra-abdominal sepsis from colonic perforation is a surgical emergency with high mortality. While diverticulitis is a common cause in older adults, its presence in young, healthy individuals suggests additional etiologies. Parasitic infestations such as Ascaris lumbricoides, though rare in developed regions, can complicate outcomes.
Case presentation: A 35-year-old previously healthy male presented with 3 days of severe abdominal pain and vomiting. CT scan revealed pneumoperitoneum. Emergency laparotomy showed perforated sigmoid diverticulitis with fecal peritonitis. A Hartmann’s procedure was performed with an open abdomen due to gross contamination. Despite surgery, the patient developed persistent sepsis, requiring seven relook laparotomies. During the fourth, live Ascaris worms were seen emerging from the bowel during ileostomy creation, prompting Albendazole treatment. Histopathology confirmed diverticulitis with perforation. Recovery was complicated by multidrug-resistant infections, anemia, malnutrition, and thrombotic events, prolonging ICU stay.
Discussion: This case highlights how unrecognized parasitic infestation can worsen intra-abdominal sepsis. Ascaris may contribute to mucosal damage, obstruction, and inflammation, exacerbating outcomes. Early hypoalbuminemia might have reflected chronic enteric loss or parasite burden.
Conclusion: In endemic areas, chronic helminthic infections should be considered in young patients with unusual presentations or poor postoperative progress. Timely recognition may impact treatment and recovery.

References

Figure 1: CT Abdomen with Contrast showing Moderate Pneumoperitoneum
Figure 2: Worm coming out of iliostomy
Figure 3: acsaris
Figure 4 : CT Chest showing bilateral moderate pleural effusion more on the right side with underlying lung consolidation collapse.
Figure 5 : US Neck showing Left internal jugular vein central line with echogenic thrombus not completely occluding the lumen.

Introduction

Fusobacterium nucleatum (Fn) and other species typical of the oral cavity are implicated in colorectal oncogenesis. The pathogenesis of serrated polyposis syndrome (SPS), the most common polyposis syndrome, remains unknown, and to date, the oral and gut microbiota of these patients has not been characterized.

Aims & Methods

The primary objective of this study was to describe and compare the composition of the oral and gut microbiota in individuals with SPS versus individuals without polyps, with sporadic serrated polyps, and with adenomas.
A prospective, observational, and bicentric study was conducted. Clinical and endoscopic data were collected, along with information obtained from a questionnaire on diet and dental health. Additionally, saliva and stool samples were obtained from 126 individuals divided into four groups: SPS (n=32), serrated (n=30), adenoma (n=32), and control (n=32). The microbiota was analyzed using 16S rRNA amplicon sequencing, and qPCR was performed for the detection of Fn.

Results

The main clinical, dietary, and dental health characteristics of the groups are presented in Table 1. Regarding the oral microbiota, no differences were observed in alpha diversity (species variety) among the groups. However, the composition of the oral microbiota in the SPS group showed significant differences compared to the other groups, as evidenced by a greater unweighted UniFrac distance (differences in bacterial taxonomy) (p<0.001). In the gut microbiota, the adenoma group exhibited lower species richness than the control group, according to the Chao1 index (p=0.03), while no differences were found in the other groups. Statistically significant differences in beta diversity, measured using unweighted UniFrac distance, were observed between the SPS group and the adenoma and control groups (p<0.001).
Regarding taxonomy, Porphyromonas gingivalis, an oral bacterium associated with colorectal cancer (CRC) development and progression, showed higher oral abundance in the SPS group compared to the control and adenoma groups (p<0.05; FDR p=0.104). Treponema denticola and Prevotella intermedia, two oral bacteria related to CRC, were more abundant in the SPS group than in the control group (p<0.05; FDR p=0.09). Additionally, Peptoanaerobacter stomatis, an oral bacterium linked to CRC via the serrated pathway, was more prevalent in the SPS group compared to the serrated and adenoma groups (p<0.05; FDR p=0.26).
No differences in the abundance of Fn were found among the groups, either in saliva or stool samples.

Conclusion

The oral and gut microbiota of individuals with SPS exhibit a distinct bacterial composition compared to individuals without polyps and those with adenomas. Furthermore, certain oral bacteria associated with colorectal carcinogenesis are increased in SPS patients.

Disclosure

There are no conflicts of interest to declare.

Introduction

The neutrophil-lymphocyte ratio (NLR) has been used as a predictor of survival in critically ill patients. However, there are scarce studies that evaluate the relationship between NLR and alcoholic hepatitis.

Aims & Methods

Objectives: To determine the association between NLR with mortality and the degree of acute-on-chronic liver failure (ACLF).
A longitudinal, retrospective, observational and descriptive cohort study was conducted. The subjects met criteria for alcohol hepatitis established by the National Institute on Alcohol Abuse and Alcoholism. Patients with concomitant infections or conditions that could alter the NLR were excluded.
Statistical analysis was performed with the Jamovi program. To compare clinical values, Student's T-test or Mann Whitney U test were performed according to the distribution of the data. The association analysis between NLR and 30-day mortality, as well as the association between NLR and ACLF degrees, were carried out using a point-biserial correlation. An ROC curve was performed using GraphPad Prism version 10.2.3 and Microsoft Excel software to establish the cutoff point of the neutrophil-lymphocyte ratio, as well as determine the sensitivity and specificity of the model to predict 28-day mortality.

Results

Eighty-nine patients were included, 86 (96%) men and 3 (4%) women. There was significant difference between patients who died within 28 days compared with those who survived (Table 1). The mean NLR value in patients who survived was approximately four times the value presented in patients who died within 28 days (p < 0.001). A gradual increase in severity-dependent NLR was identified based on the CLIF-C ACLF SCORE. The cutoff point of the neutrophil-lymphocyte ratio was >12.9 (AUC 0.986), with a p value <0.0001, sensitivity 92.7% and specificity 94.1% (95% CI).

Conclusion

The association between high NLR levels and mortality within 28 days is confirmed. Furthermore, there is an association between NLR and the severity of ACLF. Therefore, the NLR could be a useful prognostic factor in the clinical practice for alcoholic hepatitis.

References

Forrest, E. H., Storey, N., Sinha, R., Atkinson, S. R., Vergis, N., Richardson, P., Masson, S., Ryder, S., Thursz, M. R., Allison, M., Fraser, A., Austin, A., McCune, A., Dhanda, A., Katarey, D., Potts, J., Verma, S., Parker, R., Hayes, P. C., & Group, =STOPAH N L R. (2019). Baseline neutrophil-to-lymphocyte ratio predicts response to corticosteroids and is associated with infection and renal dysfunction in alcoholic hepatitis. Alimentary Pharmacology &amp; Therapeutics, 50(4), 442–453. https://doi.org/10.1111/apt.15335
Velarde-Ruiz Velasco, J. A., Higuera-de la Tijera, M. F., Castro-Narro, G. E., Zamarripa-Dorsey, F., Abdo-Francis, J. M., Aiza Haddad, I., Aldana Ledesma, J. M., Bielsa-Fernández, M. v, Cerda-Reyes, E., Cisneros-Garza, L. E., Contreras-Omaña, R., Reyes-Dorantes, A., Fernández-Pérez, N. J., García-Jiménez, E. S., Icaza-Chávez, M. E., Kershenobich-Stalnikowitz, D., Lira-Pedrín, M. A., Moreno-Alcántar, R., Pérez-Hernández, J. L., … Torre-Delgadillo, A. (2020). Consenso Mexicano de hepatitis alcohólica. Revista de Gastroenterología de México, 85(3), 332–353. https://doi.org/https://doi.org/10.1016/j.rgmx.2020.04.002

Disclosure

No conflict of interest.

Clinical Case Summary

A 19-year-old man with a long-standing history of recurrent abdominal pain and a recent episode of melena of unknown origin. He presented to the emergency department (ED) with hematochezia and asthenia, with a drop in hemoglobin to 8.9 g/dL. Upper and lower endoscopy were inconclusive. Capsule enteroscopy revealed a double-lumen sign and mildly erythematous mucosa, raising suspicion of Meckel’s diverticulum. A technetium-99m pertechnetate (Tc-99m) scan confirmed the presence of ectopic gastric mucosa. The patient subsequently underwent enterectomy, and histological analysis confirmed gastric mucosal heterotopia.
A 13-year-old man with a history of iron-deficiency anaemia requiring transfusion at 7 years old, and previous episodes of abdominal pain due to ileo-ileal intussusception. He had
undergone an inconclusive exploratory laparoscopy. He was admitted to the ED with melena and hypogastric pain. Blood tests revealed hemoglobin of 12.9 g/dL. Abdominal ultrasound showed thickening of the distal ileum over 11 cm, without signs of intussusception. Capsule enteroscopy revealed a segment of circumferential edema and erythema in the ileum, with absence of a clear villous pattern and an appearance suggestive of gastric mucosa. A Tc-99m scan confirmed the presence of ectopic gastric mucosa. Exploratory laparoscopy identified a 10–15 cm segment with gastric fold-like appearance within otherwise normal small intestinal mucosa, in the absence of a diverticulum. Histological analysis confirmed gastric mucosal heterotopia.
Gastric heterotopia is an important differential diagnosis in patients with gastrointestinal bleeding and can occur independently of the presence of Meckel’s diverticulum. The authors highlight the role of capsule enteroscopy in the diagnostic algorithm.

Introduction

Prophylactic clip closure is known to avoid delayed adverse events post colorectal endoscopic submucosal dissection (ESD).¹ It may also improve reduce the duration of hospitalization.² However, endoscopic clips have limitation of defect size that can be completely closed due to their limited opening width. Other studies have suggested methods to completely close a mucosal defect using special devices^{3, 4} which have limitations of availability, learning curve, scope removal and reinsertion, and negotiation in narrow spaces. An ideal closure technique has been described as a technique which is technically easy, requiring no special accessories or endoscopes, managed through accessory channel without endoscope removal, possible in narrow space, creating no dead space, and being economical.⁵ We recently developed a Clip with Line Pulley Securing (CLiPS) technique to completely close large mucosal defect which fulfils the criteria for an ideal closure technique.⁶

Aims & Methods

The aim of this study was to report the feasibility and efficacy of CLiPS technique for closure of large mucosal defects following colorectal ESD. This study retrospectively evaluated 53 consecutive patients who underwent closure using CLiPS technique post colorectal ESD. CLiPS technique involves deployment of a clip with nylon line on the edges of the ulcer which are approximated using external counter traction. An endoloop is deployed to fix the line. The principle is supporting the clip line with an endoloop and creating a pulley system by giving external countertraction to the line, to facilitate a strong, stable approximation of edges, thereby making the defect more linear. The line is cut and final closure is completed with conventional clips. The primary outcomes were complete closure rate and adverse events. The secondary outcomes were closure time and defect size.

Results

The lesion characteristics are given in the 'table'. Complete closure was achieved in 94.3%(50/53) of cases. The mean defect size was 48.2­+18.8 mm and median closure time was 14(5-58) minutes. There was one case each of delayed bleeding and perforation which were managed by endoscopic clipping.

Conclusion

CLiPS technique has reasonable outcomes and can be considered to be a safe and effective closure method for large post ESD colorectal defects. Further prospective study may be undertaken to establish wider acceptability of this method.

References

1. Liu M, Zhang Y, Wang Y, et al. Effect of prophylactic closure on adverse events after colorectal endoscopic submucosal dissection: A meta‐analysis. Journal of Gastroenterology and Hepatology. 2020 Nov;35(11):1869-77.
2. Abe S, Saito Y, Tanaka Y, et al. A novel endoscopic hand-suturing technique for defect closure after colorectal endoscopic submucosal dissection: a pilot study. Endoscopy. 2020 Sep;52(09):780-5.
3. Farha J, Ramberan H, Aihara H, et al. A novel through-the-scope helix tack-and-suture device for mucosal defect closure following colorectal endoscopic submucosal dissection: a multicenter study. Endoscopy. 2023 Jun;55(06):571-7.
4. Keihanian T, Zabad N, Khalaf M, et al. Safety and efficacy of a novel suturing device for closure of large defects after endoscopic submucosal dissection (with video). Gastrointestinal Endoscopy. 2023 Sep 1;98(3):381-91.
5. Nomura T, Sugimoto S, Temma T, et al. Suturing techniques with endoscopic clips and special devices after endoscopic resection. Digestive Endoscopy. 2023 Mar;35(3):287-301.
6. Minato Y, Ohata K, Kimoto Y, et al. A modified approach for closing endoscopic submucosal dissection defects using clip with line pulley securing technique and endoloop. VideoGIE. 2024 Mar 27.