Introduction

Cannulation of the papilla of Vater is a pivotal step in endoscopic retrograde cholangiopancreatography (ERCP), directly impacting technical success and complication risk. (1) While factors such as endoscopist experience and anatomical variants are known to influence outcomes, (2) the role of papillary morphology remains understudied, particularly in Latin America. Morphology-based risk stratification may aid in anticipating the need for advanced cannulation techniques or expert-level intervention.

Aims & Methods

We prospectively enrolled adults with an intact, naïve major duodenal papilla undergoing ERCP at a high-complexity institution in Bogotá, Colombia. Patients with surgically altered anatomy or periampullary tumors were excluded. Papilla morphology was classified macroscopically according to Haraldsson et al. (3) Difficult cannulation was defined by ESGE criteria: >5 papilla contacts, >5 minutes to cannulate after visualizing the papilla, or ≥2 unintentional pancreatic duct guidewire passes. We recorded clinical and procedural variables, including use of advanced cannulation techniques and complications. Associations were assessed through bivariate comparisons using Fisher’s exact test and odds ratios with 95% confidence intervals (p < 0.05).

Results

58 patients were included (mean age 59.9 years; 63.8% female). The most frequent indication for ERCP was choledocholithiasis (81.0%). Papilla types were: type 1 (63.8%), type 3 (27.6%), type 2 (6.9%), and type 4 (1.7%). Difficult cannulation occurred in 8 cases (13.8%), with overlapping criteria: >5 contacts (n=5), >5 minutes (n=3), and ≥2 pancreatic guidewire passes (n=3). Difficult cannulation was more frequent in type 1 (13.5%) and type 3 (12.5%) papillae and occurred in the single type 4 case; none in type 2. The mean number of contacts with the papilla was 2.4 (range 0–16). Use of advanced cannulation techniques was required in 20 cases (34.5%). Cannulation time was significantly longer when advanced techniques were required, with a median of 21.2 minutes and a mean of 27.6 minutes, compared to 0.5 and 0.9 minutes, respectively, in cases managed conventionally. Post-ERCP prophylaxis measures were used in 35 patients (60.3%), including diclofenac (37.9%), aggressive hydration (32.8%), and pancreatic stenting (27.6%). Three patients (5.2%) received all three preventive measures. Complications included pancreatitis (n = 4, 6.9%) and cholangitis (n = 2, 3.4%). Complication rates did not significantly differ according to papilla type (p = 0.68). No significant difference in pancreatitis incidence was observed between patients who did and did not receive prophylactic measures (p = 1.0; OR 0.64, 95% CI 0.04–9.48). The incidence of post-ERCP pancreatitis was 8.3% in type 1 and 25.0% in type 2 papillae, with no cases observed in type 3 or type 4 papillae. However, the association between papilla morphology and pancreatitis occurrence was not statistically significant (p = 0.268).

Conclusion

Type 1 and type 3 papillae were associated with greater cannulation difficulty, though complications did not differ significantly by morphology. These findings support a growing body of evidence linking papillary type to ERCP complexity. While limited by sample size and the absence of endoscopist stratification, the prospective design, standardized use of ESGE criteria, and regional focus contribute valuable insight into procedural risk. This study provides a foundation for considering papilla morphology in preprocedural planning and for guiding training priorities in high-complexity endoscopy units.

References

1. Liao WC, Angsuwatcharakon P, Isayama H, Dhir V, Devereaux B, Khor CJL, et al. International consensus recommendations for difficult biliary access. Gastrointest Endosc. 2017 Feb;85(2):295–304.
2. Testoni P, Mariani A, Aabakken L, Arvanitakis M, Bories E, Costamagna G, et al. Papillary cannulation and sphincterotomy techniques at ERCP: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2016 Jun 14;48(07):657–83.
3. Haraldsson E, Kylänpää L, Grönroos J, Saarela A, Toth E, Qvigstad G, et al. Macroscopic appearance of the major duodenal papilla influences bile duct cannulation: a prospective multicenter study by the Scandinavian Association for Digestive Endoscopy Study Group for ERCP. Gastrointest Endosc. 2019 Dec;90(6):957–63.

Introduction

Recommendations for bowel preparation prior to capsule endoscopy exploration in clinical guidelines are controversial and unclear.

Aims & Methods

To assess the contribution of the Boston cleansing scale (BBPS) in the previous colonoscopy, the discontinuation of iron therapy, a low-fibre diet, and the use of simethicone prior to capsule ingestion to obtain adequate visualization during capsule endoscopy exploration of the small bowel.
Prospective study of capsule examinations. In our centre, capsule preparation includes a fibre-free diet the day before, liquids only the evening before, 8-hour fasting, and simethicone. Capsule preparation is categorized as adequate/inadequate according to the Brotz scale.
Statistical analysis was performed with SPSS software.

Results

A total of 117 capsule explorations were analysed: 79 (67.5%) had adequate preparation and 38 (32.5%) had inadequate preparation.
The factors in which the association was studied and the major regression model are shown in Table 1. In the final model were included the Boston score for the right colon (p=0.032; OR=2.639) and transverse colon (p=0.002; OR=0.191), after ruling out confounding and interaction. Homer-Lemeshow test with p value 0.246. Specificity of 91.1%, sensitivity of 18.4%, and accuracy of 67.7%. Area under the ROC curve was 0.305 (0.205–0.404).
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Conclusion

1. In our series, the use of simethicone, a low-fiber diet, and the discontinuation of iron therapy did not contribute to adequate preparation for capsule exploration.
2. Meanwhile, the Boston score for the right and transverse colon in pre-capsule colonoscopy can help predict capsule cleanliness.
3. Further studies are needed to find variables that help predict adequate preparation for capsule endoscopy.

References

Rondonotti E, Spada C, Adler S, 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): 423-446.

Introduction

Symptomatic Uncomplicated Diverticular Disease (SUDD) is a widespread gastrointestinal condition linked to sedentary lifestyles and unhealthy dietary patterns, often requiring medications. Mediterranean Diet (MedDiet) and physical activity (PA) have been proposed as potential protective factors against various diseases, including SUDD.

Aims & Methods

The aim is to evaluate if a counseling program which encourages MedDiet and PA can influence SUDD symptoms, drug use and quality of life.
In this prospective, monocentric, observational study, we enrolled consecutive patients with diagnosis of SUDD at colonoscopy. They were divided into two groups: the Study Group (SG) received a 3-month lifestyle counseling promoting MedDiet and regular PA, while the Control Group (CG) followed a free diet. Lifestyle counseling consisted of 3 medical visits (every 6 weeks) and 4 phone calls (every 2 weeks). Patients were evaluated at baseline (T0), 12 weeks (T12, end of counseling) and 52 weeks (T52). We collected clinical data and anthropometric data, MediLite score (a validated adherence score for MedDiet), questionnaires assessing PA and symptom burden expressed both as specific item and as multiparametric scores including Irritable Bowel Syndrome Severity Scoring Scale (IBS-SSS) and Visual Analogical Scale for patients with SUDD (VAS-DICA), and SF-12 for the assessment of quality of life.

Results

84 patients (F=48) were enrolled, of whom 41 subjects were included in SG while 43 in CG. At T12, while CG characteristics remain unchanged, the Medi-Lite score in SG rose from 9,12±2,0 to 10,3±2,23 (p=0,011) and daily walking time increased, with 92,5% of SG reporting walking for 30–60 minutes daily compared to 42,5% at T0 (p< 0,001). At T52, SG had still a high % of patients with high adherence to MedDiet (MediLite >10) (from 46,34% to 56,01%, p<0.001) and PA adherence was 63,41% (p=0,001). Compared to CG, SG showed a reduction of abdominal pain (SG/CG at T0 51,22/58,14%, at T12 24,4/46,51%, p=0,012, at T52 31,71/53,49%, p=0,018), constipation (at T0 19,51/25,58%, at T52 7,32/44,19% p<0,001), and IBS-SSS score (at T0 141±98,5/150±94,1, at T12 71±61,6/123±104, p=0,002, at T52 69,1±52,4/101±97,5, p<0,001). Subjects in SG who reported medication use for SUDD dropped from 43,9% to 26,83% at T12 and 24,39 at T52 (p<0,05) while an increase of overall medication use was observed in the CG (from 25,58 to 51,16, and 83,72% at T0, T12, and T54, respectively), in particular regarding the use of rifaximin (from 6,98% to 13,95% and 34,88%), both at T12 (p=0,01) and T52 (p<0,001). Overall, the CG had a higher rate of diverticular disease complications including acute diverticulitis, need for hospitalization and surgery: 12 vs 1 patient in the CG vs SG, respectively (at T52=0,001).

Conclusion

Higher adherence to MedDiet and PA are associated with symptom relief, reduced use of medication, and reduction of disease-associated complications in patients with SUDD, suggesting a therapeutical role of MedDiet and PA which goes beyond the already recognized preventive action. Clinical benefits of a 3-month counseling may still be present at 1 year.

Introduction

Patients with locally advanced rectal cancer (LARC) who have a complete clinical response (cCR) to nCRT may opt for organ preservation, watch & wait – (W&W). This consists of an intense surveillance program including serial endoscopies, pelvic MRI, CEA, and CT scans to detect recurrent disease at an early stage. However, identifying residual or recurrent lesions endoscopically - particularly in patients with prior radiotherapy - can be challenging due to mucosal changes such as friability and neovascularization. In this context, we developed a novel deep learning model to assist in the detection of residual or recurrent rectal cancer lesions during proctosigmoidoscopy.

Aims & Methods

We trained a convolutional neural network (Wide ResNet-101-2) on a dataset of 1,795 annotated frames from proctosigmoidoscopy exams of 97 patients treated at University Hospitals Liverpool, a tertiary referral center. Residual or recurrent disease was defined by histopathological confirmation via biopsy or surgical specimen. The dataset was split into training and testing cohorts using a 90/10% patient-level split. The model’s diagnostic performance was evaluated using sensitivity, specificity, accuracy, positive predictive value (PPV), negative predictive value (NPV), and the area under the receiver operating characteristic curve (AUROC).

Results

Out of 97 patients, 24 (363 frames) had confirmed residual or recurrent disease, while 73 (1,432 frames) presented normal rectal mucosa. The model achieved an overall accuracy of 92.8%, with a sensitivity of 80.0%, specificity of 97.3%, PPV of 90.9%, NPV of 94.0%, and an AUROC of 0.886.

Conclusion

To the best of our knowledge, this is the first deep learning model specifically developed for the detection of residual or recurrent disease following in W&W patients during endoscopic examination. This tool has the potential to enhance early lesion detection, guide clinical decision-making, and increase opportunities for organ-preserving, less invasive therapeutic strategies.

Introduction

Steatotic liver disease (SLD) in non-obese individuals (body mass index -BMI- <25) is an increasingly recognized clinical entity, distinct from the classic metabolic-associated fatty liver disease typically linked to obesity. Despite growing awareness, the characteristics, associated conditions, and treatment response of this phenotype remain poorly understood. This study aimed to evaluate clinical, biochemical, and histological characteristics in this population and to assess the impact of targeted interventions on liver-related outcomes.

Aims & Methods

We conducted a retrospective monocentric analytical study including 50 non-obese patients (BMI <25) diagnosed with SLD by ultrasound. Patients were stratified based on associated comorbidities, including coeliac disease, inflammatory bowel disease (IBD), type 2 diabetes, and hypertension. Comparative statistical analysis was performed using chi-square and Student’s t-test; p-values <0.05 were considered statistically significant.

Results

Out of 162 patients followed for SLD, 30.86% (n=50) were classified as non-obese, among which 22% (n=11) were underweight. The mean age was 40.6, with a slight female predominance and a sex ratio M/F of 0.81.
SLD was MASLD in 26% of patients (n=13), among which 9 patients had type 2 diabetes, and 4 patients had arterial hypertension. MASH was diagnosed in 7 patients of this group.
SLD was secondary to other causes of steatosis in 74% of cases (n=37): 38% had coeliac disease (n=19), 30% had inflammatory bowel disease (n=15), 4% had thyroid dysfunction (n=2), and 2% had LPAC syndrome (n=1).
Liver function abnormalities were found in 58% (n=29) of patients.
Patients with coeliac disease who underwent liver biopsy showed significantly higher rates of steatohepatitis (grade 2-3) compared to non-coeliac patients (68.4% vs 40%, p=0.03).
After one year of follow-up, liver enzyme normalization was observed in 75% of patients who received targeted treatment (gluten-free diet or optimized management of comorbidities) along with adapted physical activity and a weight loss goal of 3-5%, compared to 33.3% in untreated patients (p=0.01).
Histological improvement (≥1 grade regression of steatohepatitis) was documented in 44.4% of biopsied patients post-intervention, with a statistically significant association between adherence to gluten-free diet and histological regression in coeliac patients (p=0.02).
No significant association was found between presence of diabetes or hypertension and severity of liver histology (p>0.05).
Evaluation of liver fibrosis showed F0-F1 in 70% (n=35) and F2 in 12% of patients (n=6). Fibroscan stages remained stable in all these patients during follow-up, with no progression beyond F2.

Conclusion

In non-obese individuals, SLD is frequently associated with immune-mediated comorbidities, particularly coeliac disease and IBD, and characterized by mild fibrosis. Targeted treatment strategies, particularly in coeliac patients, significantly improve liver biochemistry and histological status. These findings support the need for systematic etiological screening and personalized therapeutic approaches in non-obese patients with hepatic steatosis.

Introduction

Advanced biological therapies have improved outcomes of patients diagnosed with Inflammatory Bowel Diseases (IBD) such as Ulcerative colitis (UC) and Crohn’s disease (CD). However, nonresponse or loss of response remains a significant challenge. Primary sclerosing cholangitis (PSC) is associated with IBDs, but the impact of concurrent PSC on response to IBD therapy is not well explored.

Aims & Methods

This study compared therapy response to IBD treatment with Infliximab, Vedolizumab and Ustekinumab in patients diagnosed with PSC and IBD (PSC/IBD group) versus patients diagnosed with IBD only (control group). Therefore, we identified 46 patients in the PSC/IBD group and 180 in the control group treated with Infliximab, Vedolizumab and/or Ustekinumab at our IBD outpatient clinic at Charité – Universitätsmedizin Berlin. Propensity score matching was employed to match the groups with a ratio of 1:1 based on age, sex, BMI, smoking status, Charlson Comorbidity Index (CCI), IBD subtype, duration of IBD, age at IBD diagnosis and Montreal-Classification (tolerance = 0.2).
The primary outcome was clinical therapy response within 20 weeks, defined as remission (partial Mayo Score (pMS) ≤ 1/Harvey-Bradshaw-Index (HBI) < 5) or partial response (decrease of pMS ≥ 2/HBI > 3). Group differences were compared using Fisher´s Exact test.
Secondary outcomes included time to loss of response, mucosal healing (defined as no or mild inflammation e.g. Mayo Endoscopic Score 0 or 1) and decreased levels of C-reactive Protein (CRP) < 5mg/l and faecal calprotectin (FC) < 50 mg/g. Only patients achieving clinical remission or partial response were included in the secondary analyses.

Results

After matching, 46 patients per group were analysed, with a total of 136 treatments administered. The cohort demographics and disease characteristics were balanced between PSC/IBD group and control group with all p-values > 0,05 (mean age: 39.7 ± 12.4 vs. 39.9 ± 13.9 years; male sex: 31 (67.4%) vs. 24 (52.2%); mean BMI: 23.1 ± 3.9 vs. 23.8 ± 4.8 kg/m2; smokers: 9 (20.0%) vs. 13 (31.7%); mean CCI 0.6 ± 1.1 vs. 0.5 ± 1.0). In both groups 34 (73.9%) patients having an UC diagnosis and 12 (26.1%) a CD diagnosis.
While clinical response rates did not significantly differ between groups in patients receiving Infliximab or Vedolizumab, in patients treated with Ustekinumab clinical remission and partial response rates were significantly lower in the PSC/IBD group (p=0.04, Table 1).
The time to loss of response was not different between groups for any of the therapies. Mucosal healing rates were lower in the PSC/IBD group compared to controls as well as decreased levels of CRP and FC across all therapies (Table 1).

Table 1 Comparison of therapy response to IBD treatment with Infliximab, Vedolizumab and Ustekinumab between PSC/IBD group and control group

Conclusion

Infliximab and Vedolizumab appear equally efficient for achieving clinical response in IBD patients with and without PSC, while the efficacy of Ustekinumab is significantly lower in IBD patients with PSC. Future prospective data is needed to strengthen our knowledge of treatment outcomes in this population.