Introduction

Gastroenterology is a medical specialty that includes several areas of study. Endoscopy occupies a central role in professional practice, whether in hospitals or in the private sector. The quality of initial training and the different needs of trainees are key to the quality of care delivered to the population. This study aims to assess endoscopic training experience during fellowship.

Aims & Methods

This is a cross-sectional, multicenter study conducted on gastroenterology residents practicing endoscopy and in the final phase of their curriculum (6th, 7th and 8th semesters). Postgraduated doctors have been excluded from the study. An electronic survey made by Google Forms and was sent nationwide on January 9, 2024. The survey consisted of 42 questions divided into 3 parts: The first part focused on the participants' socio-demographic data and their endoscopic experience, the second part focused on the quality of training of core endoscopic skills (cognitive and motor skills) during fellowship where a 5-point Likert scale was used to express residents' satisfaction with their skills, ranging from 1="very dissatisfied", 2="dissatisfied", 3="neither satisfied nor dissatisfied", 4="satisfied" and 5="very satisfied". The third part included questions in which participants expressed their needs and expectations for improving their training in endoscopy. A statistical analysis using the Student-t test and the Fisher’s exact test were performed. P values of <0.05 were considered statistically significant. Data were analyzed using Jamovi (Version 2.3).

Results

We were able to collect data from 56 respondents. Most were female residents n=40 (71.4) with a mean age of 29.2 ± 2.5 years. The majority of fellows started practicing EGD in their 4th semester (91.1%), and colonoscopy in their 6th semester (57%). On average, the fellows are supervised by 5 senior doctors, including 2 who practice interventional endoscopy. Furthermore, 37.5% of participants report performing approximately more than 100 EGDs, 14.2% more than 100 colonoscopies, 80.4% report that they have performed less than 20 endoscopic variceal ligation and 14.3% have performed more than 10 polypectomies. An average rating score of 3.34 (1= very dissatisfied; 5= very satisfied) concerning the quality of training and feedback on cognitive aspects of endoscopy was found and we reported greatest emphasis for Procedure indication/contraindication and least on Capsule endoscopy interpretation.
The quality of training in technical aspects of endoscopy was rated higher (average rating score of 3.5). We reported greatest emphasis for Withdrawal/mucosal inspection and least on Esophageal dilation.
A significant association between motor skills and cognitive skills was found with a p<0.001.
Finally, to improve their training, 87.5% of respondents considered simulation to be important/very important, 98.2% of respondents intend to complete their endoscopy training at the end of their curriculum, and 87.5% are prepared to finance such a project (median: 1000 USD [1000;3000]).

Conclusion

Despite a significant improvement in training sites and technical facilities, training in endoscopy in healthcare institutions does not yet provide all the cognitive and technical skills required to enable fellows to be fully autonomous. With the development of endoscopic procedures, it seems essential for fellows to be able to perform more standard endoscopic procedures such as polypectomy and mucosectomy by the end of their curriculum. This may involve introducing regular endoscopy conferences and simulation training as a part of the curriculum.

Clinical Case Summary

A 68-year-old woman presented after 24 hours of painless jaundice, preceded by 48 hours of dark urine and pale stools without pruritis. No history of weight loss, recent foreign travel, or high risk behaviours. She denied any illicit drug or alcohol abuse. Her co-morbidities included pre-diabetes, and obesity and only took over-the-counter vitamin supplementation with no new or regular prescribed therapies. On clinical examination, she was fully alert with jaundice with no stigmata of chronic liver disease and haemodynamic stable.

Liver tests at presentation (normal in 2020) were ALT 766 U/L, AST 984 U/L, bilirubin 463, ALP 314 U/L. PT 35.3s, APTT 45.5s, TT 26.2s and albumin was 33 g/L. Haemoglobin (139 g/L), platelet count (158 x109/L), and normal eosinophil count (0.89 x109/L). Renal function was unremarkable. Arterial blood gas demonstrated a pH 7.4, Lactate 1.8, glucose 6. CT scan demonstrated moderate volume ascites and a grossly dilated gallbladder. No intra- or extra-hepatic duct dilatation and patent vasculature. Homogenous ANA 1:400, strongly positive SMA, polyclonal gammopathy (IgG 18.8, IgM 5.5, IgA 4.2) and negative AMA/ LKM. Viral hepatitis screen was negative. Given the severity of hepatic failure, she was referred for consideration of transplantation.

This lady presented with an acute hepatocellular pattern of liver injury with hepatic failure. It came to light that her injury was a consequence of exposure to ashwagandha. Although her exposure was in 2021, a latency period prior to drug-related injury is not unusual. Previous case series have shown similar patterns of injury with ashwagandha but no hepatic failure.

1. How do we overcome the challenges distinguishing drug-induced liver injury as a cause of acute hepatic failure, particularly when markers of alternative aetiology are present?
2. What is the role of steroids in patients ?
2. What is the relationship between DILI from herbal/ dietary supplementation and acute liver failure?

References

1. Katarey D, Verma S. Drug-induced liver injury. Clin Med. 2016;16(Suppl 6):s104-s109. doi:10.7861/clinmedicine.16-6-s104
2. Chalasani N, Bonkovsky HL, Fontana R, et al. Features and Outcomes of 899 Patients With Drug-Induced Liver Injury: The DILIN Prospective Study. Gastroenterology. 2015;148(7):1340-52.e7. doi:10.1053/j.gastro.2015.03.006
3. Paul S, Chakraborty S, Anand U, et al. Withania somnifera (L.) Dunal (Ashwagandha): A comprehensive review on ethnopharmacology, pharmacotherapeutics, biomedicinal and toxicological aspects. Biomed Pharmacother. 2021;143:112175. doi:10.1016/j.biopha.2021.112175
4. Mandlik Ingawale DS, Namdeo AG. Pharmacological evaluation of Ashwagandha highlighting its healthcare claims, safety, and toxicity aspects. J Diet Suppl. 2021;18(2):183-226. doi:10.1080/19390211.2020.1741484
5. Björnsson HK, Björnsson ES, Avula B, et al. Ashwagandha-induced liver injury: A case series from Iceland and the US Drug-Induced Liver Injury Network. Liver Int. 2020;40(4):825-829. doi:10.1111/liv.14393

Introduction

While randomized studies have shown that Amgevita (an adalimumab biosimilar) and Humira (adalimumab originator) are equivalent, concerns persist among patients and prescribers as to its efficacy. Patients switching to a medicine they perceive as lower cost may experience a ‘nocebo’ effect, whereby expectations of poorer efficacy may lead to worse clinical outcomes, resulting in an unmeasured health economic burden.

Aims & Methods

70 patients partook in a biosimilar switch study at our centre in August 2020, undergoing a change in treatment from Humira to Amgevita. Baseline clinical data obtained included faecal calprotectin, drug and drug antibody levels, Harvey-Bradshaw (HBI) and Partial-Mayo scores. Patient-Reported Outcomes (PROs) were recorded through the IBD control-8 (IBDC8) and IBCD visual analogue scale (IBDQ-VAS). Patients took psychometric tests 8 weeks pre-switch, including the ‘Beliefs about Medicines’ questionnaire (BMQ), used to assess beliefs about prescribed medications, the ‘Health Anxiety Index’ (HAI), used to identify patients with high levels of concern about their health, and the EQ-5D questionnaire, used to measure health-related quality of life. The original study found no significant differences in clinical and PROs at 8-week follow-up. We planned to conduct a 32-month follow-up on these patients to examine for temporal changes in outcomes, and whether certain variables could predict the patients experiencing a ‘nocebo’ effect. Approval was obtained from the hospital ethics committee. Patient information from the original study was stored on an excel database. We retrospectively obtained clinical data from electronic records and lab data. Questionnaire results were obtained from clinic appointments.

Results

70 patients were included in the study. 41 male, 29 female. 54 patients had Crohn’s, 13 UC, and 4 indeterminate colitis. 25.7% of patients reported adverse events post-switch, with 33.3% of these patients switching back to Humira. The most common side effects were skin related (8.6%), injection site related (5.7%), and headaches (2.8%). 8.6% of patients felt the medication to be less effective without specific symptoms. 32-months post switch, 72.7% remained on Amjevita, 9.1% had switched back to Humira, 7.6% had switched to another biologic as clinical non-responders, 10.6% had stopped biologic treatment due to surgery or clinical remission.
Median scores were calculated at 8 weeks pre and post-switch, and at 32 months. HBI scores were 2, 1 and 1 respectively, with scores of 1, 0 and 0 in the switchback group. IBDC8 scores were 12, 13 and 14 overall, with scores of 12, 10 and 14 in the switchback group. IBDQ-VAS scores were 87, 80 and 90 overall, with scores of 100, 100 and 85 in the switchback group. Median HAI scores were lower in the switchback group; scoring 12 versus 17 overall. Median scores in four domains of the BMQ questionnaire; general harm, general overuse, specific concerns and specific necessity were lower in the switchback group. Scores were 12, 12, 8, 7, versus overall scores of 21, 14, 10, and 9 respectively, indicating more negative attitudes towards medicines in the switchback group.

Conclusion

Our study found no negative impact in clinical outcomes and PROs in patients switching from Humira to Amgevita at 32-months post-switch. Patients that had more negative attitudes to medicines in the BMQ questionnaire were more likely to switchback to Humira suggesting a nocebo effect. Enhanced patient education may help mitigate the nocebo effect observed in our study and enhance the success rate of future biosimilar switch trials.

Introduction

Experimental data have shown increased expression of angiogenic factors in portal hypertension and disruption of endothelial integrity in small intestinal mucosal vessels that is possibly correlated with antigen translocation to the portal circulation. ZO-1 is a tight junction structural protein of the intestinal epithelium. Recent data revealed that ΖΟ-1 is also expressed by endothelial and mesenchymal cells and plays a dominant role in mucosal healing. Decreased ZO-1 expression may unsettle epithelial restorative capacity following mucosal damage and contribute to the impaired endothelial integrity and bacterial translocation.

Aims & Methods

We therefore aimed to assess changes in mucosal vascular density and evaluate intestinal vessel endothelial integrity in cirrhotic patients by assessing the immunohistochemical expression of ZO-1 in small intestinal biopsy samples. Sixty-three cirrhotic patients were enrolled (M/F:35/28, mean age ±SD: 62±13) during an 18-month period. Nine non-cirrhotic patients served as controls. Patients with current or recent alcohol consumption, porto-splenic vein thrombosis, non-cirrhotic portal hypertension, hepatocellular carcinoma, transjugular intrahepatic portosystemic shunt, chronic kidney disease, celiac disease, acute infection, or any other chronic intestinal disease were excluded. Small intestine biopsy samples were taken during endoscopy and endothelial ZO-1 expression was assessed by immunohistochemistry using the indirect streptavidin biotin peroxidase method. Mucosal vascular density was evaluated by counting the number of mucosal vessels per x20 optical field. Serum lipopolysaccharide-binding protein (LBP) levels were measured by ELISA.

Results

Thirty-four patients (54%) had compensated and 29(46%) had decompensated cirrhosis. Child-Turcotte-Pugh (CTP) classification was: A 46 (73%)/B 14 (22%)/ C 3 (5%). The mean MELD score was 10.5±3.7. Mean LBP levels were 7511.97±2868.90 μg/ml. The mean number of mucosal vessels per x20 optical field did not differ between cirrhotic patients and controls (3.7±1.1 vs 3.2±0.9, p=0.238) but patients with CTP-A class had increased number of mucosal vessels compared to controls (3.8±1.1 vs 3.2±0.9, p=0.048) and CTP-B class patients (3.8±1.1 vs 3.2±0.7, p=0.045). A negative correlation was observed between the number of mucosal vessels and CTP score (r: -0.428, p=0.016). In cirrhotic patients, ZO-1 immunostaining was detected in the whole perimeter of all counted vessels per optical field in only 10/63 (16.4%) samples. Loss of endothelial ZO-1 immunostaining in more than 50% of the vessel perimeter or total loss of ZO-1 in more than 50% of counted vessels was observed more frequently in cirrhotic patient samples (42/63, 66.6%) compared to controls (1/9, 11.1%, p=0.001). Mean (±SD) LBP levels were numerically, albeit not significantly, higher in patients with than without significant loss of ZO-1 endothelial expression (7801±3698 vs 6761±1032 μg/ml, p=0.342).

Conclusion

Cirrhotic patients show increased loss of small intestinal endothelial ZO-1 expression compared to control patients. Intestinal mucosal vessel number is increased in CTP-A patients compared to control and CTP-B patients. These findings are in agreement with novel theories proposing that mechanisms leading to bacterial translocation in cirrhosis are not confined to the small intestinal lumen and merit further investigation.

Introduction

Insulinomas are rare, functioning neuroendocrine neoplasms that cause non-ketotic hypoglycemia due to hyperinsulinism. Surgery is considered the gold-standard treatment, although endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) has been recently described as a less invasive, efficient therapeutic option for these tumors. In this study, we aim to compare post-procedural outcomes of surgical resection versus EUS-RFA for pancreatic insulinomas.

Aims & Methods

All patients who underwent surgical resection or EUS-RFA for pancreatic insulinoma in our Institution were included in the study, and data from all procedures were retrospectively recorded and statistically analyzed. EUS-RFA was indicated for all subjects either unfit for surgery or unwilling to undergo surgical treatment. Patients’ baseline characteristics, location, size of insulinomas, procedural time, and intra- and postoperative outcomes were compared.

Results

From April 2012 to July 2022, 11 and 10 patients with pancreatic insulinoma underwent surgical resection and EUS-RFA, respectively. The median age was 65.5 (51-84) and 37 years (28-72, p<0.001) for the EUS-RFA and surgery cohorts, respectively. As a whole, 15 (71.4%) out of 21 were female. The median tumor size was 15mm (8-30) for the surgical group and 11mm (8-19) for the EUS-RFA group (p=0.17). The majority of the insulinomas were located in the pancreatic body (28.6%) and tail (28.6%), with no statistical difference between the two groups (p=0.16). Operative time was significantly longer in the surgical population (280min, 120-372) as compared to the endoscopic one (28min,18-40, p<0.001). Clinical success, defined as the normalization of glucose blood levels, was reached in all cases. The complication rate was significantly higher in the surgical group compared to the endoscopic group (7-63.6% vs 1-10%, p=0.01). Specifically, 7 patients in the surgical cohort developed a pancreatic fistula while one patient in the EUS-RFA population had self-limiting bleeding after the procedure. One patient of the surgical cohort underwent reoperation for an infected abdominal fluid collection.

Table 1. Characteristics of patients classified by treatments.

Conclusion

As compared to surgical resection, EUS-RFA for pancreatic insulinomas may be considered a safe and efficient treatment option with a shorter operative time and a lower rate of related complications. Prospective comparative studies are needed to ascertain the role of EUS-RFA as a treatment of choice for selected patients with pancreatic insulinoma.

References

Fahmawi Y, Mehta A, Abdalhadi H et al. Efficacy and safety of endoscopic ultrasound-guided radiofrequency ablation for management of pancreatic lesions: a systematic review and meta-analysis. Transl Gastroenterol Hepatol. 2022 Jul 25;7:30.
Zhao YP, Zhan HX, Zhang TP et al. Surgical management of patients with insulinomas: Result of 292 cases in a single institution. J Surg Oncol. 2011 Feb;103(2):169-74.

Introduction

Gastric variceal bleeding is life-threating condition with high risk of rebleed with challenging management with standard management including cyanoacrylate glue injection. We aimed to compare efficacy and safety of endoscopic ultrasonography (EUS)-guided coil embolization and cyanoacrylate injection versus EUS-guided cyanoacrylate injection alone in management of gastric varices.

Aims & Methods

Single-centre, parallel-randomized controlled trial involving 24 participants with gastric varices (GOV II and IGV I) who were randomly allocated to EUS-guided coil embolization and cyanoacrylate injection (n = 12) or EUS guided cyanoacrylate Injection alone (n = 12). Primary end points were technical and clinical success rates of both procedures. Secondary end points were reappearance of gastric varices during follow-up with rebleeding, and complication.

Results

Average size of varices were almost similar (21mm and 22mm) in both. Mean number of coils required were 2.1 per patient and volume of cyanoacrylate needed was less in combined modality group (2.5ml vs 4ml). Technical success rate was 100% in both groups. Immediate disappearance of varices was observed in 66.67% of patients treated with coils and cyanoacrylate, versus 8.33% of patients treated with cyanoacrylate alone (P=0.009). Rebleeding at 10 months occurred in none of patients treated with combined and 5 of 12 (41.66%) of those treated alone (P=0.03). 1 patient died in only cyanoacrylate group after intervention because of pulmonary embolism.

Conclusion

EUS guided coil embolization with cyanoacrylate injection achieved excellent clinical success, with lower rates of rebleeding than cyanoacrylate treatment alone. Long term follow-up and mean sample required to further Validate our data.

Introduction

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is an important diagnostic tool for suspected parenchymal lesions within the gastrointestinal tract and adjacent organs. However, the amount of literature on EUS-FNA for sampling focal liver lesions (FLLs) is limited.

Aims & Methods

This study aims at evaluating the safety and effectiveness of EUS-FNA in FLLs. Data from 88 patients who were diagnosed with FLLs by imaging and underwent EUS-FNA was reviewed in this retrospective study at the Second Affiliated Hospital of Soochow University and Ruijin Hospital of School of Medicine of Shanghai Jiao Tong University from 1 January 2017 to 31 August 2022.The EUS-FNA biopsy results were compared with the final diagnosis to evaluate the diagnostic value. Meanwhile, the relevant factors were analyzed to determine their influences on the EUS-FNA biopsy results.

Results

A final diagnosis was obtained (86 malignant and 2 benign) from the 88 cases. The overall diagnostic accuracy of EUS-FNA in FLLs was 93.18% (82／88; 95% confidence interval [CI ],87.9–98.5), with a sensitivity, specificity, positive predictive value, and negative predictive value of 93.02% (80／86; 95%CI, 87.6–98.4), 100% (2／2; 95%CI, 100–100), 100% (80／80; 95%CI, 100–100), and 25% (2／8; 95%CI, -5–55.0), respectively . The parameters related to lesion and procedure were not statistically significant between these two groups (p> 0.05) (Table 1). The number of puncture needles in the groups showed a statistically significant difference between multiple and single punctures (p = 0.001).

Conclusion

It is revealed in this study that EUS-FNA is a safe and excellent diagnostic method for FLLs with high accuracy.