Introduction

Fundic gland polyp associated with proton pump inhibitor (PPI-FGP) caused by long-term administration of proton pump inhibitors is known to be larger than normal FGP and have an edematous appearance, however, the endoscopic differentiation from normal FGP is sometimes difficult. Recently, Texture and Color Enhancement Imaging (TXI) has emerged as a novel imaged enhancement technology from Olympus Corporation and is expected to improve the visibility of the lesions by enhancing color tone and structure. The enhancement of color contrast of the mode1 is superior to that of mode2 in accordance with the color enhancement of the mode1 algorithm; however, the naturalness in mode2 is better than that of the mode1¹. Recently, we previously detected the gray color sign as a novel endoscopic finding that was clearly visible by TXI in the edematous appearance of PPI-FGP, and defined that it was gland duct dilatation below the surface containing mucus and other substances in histopathology.

Aims & Methods

The aim of this study was to evaluate the usefulness of TXI compared with white light imaging (WLI) in the visibility of the gray color sign in PPI-FGP. We enrolled 23 PPI-FGP lesions, endoscopically imaged with WLI, TXI-1, TXI-2, and Narrow Band Imaging (NBI) between April 2021 and October 2022. All PPI-FGP lesions were diagnosed by biopsy specimen histopathologically. Ten endoscopists (5 trainees, 5 experts) evaluated the images and scored the visibility of the gray color sign in TXI-1, TXI-2, and NBI compared to WLI. Visibility changes were scored by endoscopists as follows: 5, improved; 4, somewhat improved; 3, equivalent; 2, somewhat decreased; and 1, decreased. For total scores, 40 points or more was considered improved visibility, 21–39 points was comparable to WLI, and a score of less than 20 was considered decreased visibility. Inter-rater reliability was also evaluated using intraclass correlation (ICC). In addition, the color difference (ΔE*) of the gray color sign was calculated using CIELAB (color space system: L* a* b*) defined by Commission internationale de l'éclairage (CIE), and compared between WLI, TXI-1 and TXI-2.

Results

The visibility and ICC scores of TXI-1 and TXI-2 in trainees, experts, and all endoscopists are shown in Table1. TXI-1 and TXI-2 showed improved visibility of the gray color sign in PPI-FGP for all endoscopists. There was no significant difference in the visibility scores between trainees and experts for both TXI-1 and TXI-2. Compared with WLI, TXI showed improved visibility; TXI-1 82.6% (19/23), TXI-2 86.9% (20/23). In contrast, NBI showed decreased visibility; 78.2% (18/23). The intra-rater reliability for TXI-1 and TXI-2 were “almost perfect” for trainees and experts. TheΔE* values were 12.0 for WLI, 22.3 for TXI-1, and 25.9 for TXI-2 (WLI vs. TXI-1: p< 0.01, WLI vs. TXI-2: p< 0.01). In summary, improved visibility of the gray color sign in PPI-FGP was achieved for TXI-1 and TXI-2 compared to WLI for both trainees and experts and inter-rater reliability between trainees and experts was good. The ΔE* values were significantly larger in TXI-1 and TXI-2 compared to WLI.

Conclusion

The usefulness of TXI compared with WLI led to the improved visibility of the gray color sign in PPI-FGP for both trainees and experts when evaluated subjectively and objectively.

References

1. Sato T et al. Journal of Healthcare Engineering Volume 2021.

Introduction

Inflammatory bowel disease (IBD) is a growing cause for concern and often missed or not thought of among pediatric population in developing economies. It is reported that about 25% of IBDs present before the age of 20.
Growing plethora of investigations have not been able to replace the role of direct visualisation of intestinal mucosa in various colorectal issues. Macroscopic findings may or may not help in clinching the diagnosis of IBD, hence “Biopsy” remains the Elixir of diagnosis. In this article, we review and attempt to correlate colonoscopic(macroscopy) and histological (microscopy) findings of colonoscopies in pediatric population, done over a period of 1 year.

Aims & Methods

Aim and objectives: To compare macroscopic findings versus histopathology findings of colonoscopies in pediatric population in suspected IBD.
To study the correlation of macroscopic findings with histopathologic findings of colonoscopies in pediatric population and to assess the frequency and pattern of microscopic impressions of colonoscopies in our cohort.
Material and methods: A prospective observational study carried out in a tertiary referral centre in children who underwent colonoscopies, aged 1 month to 17 years over a period of 12 months.
All children whose parents consented were included in the study. Inclusion and Exclusion criteria were formulated. Informed consent was obtained from the parents. Clinical details, colonoscopy findings and histopathology reports were. A total of 135 cases were enrolled during our study period. Results were collated using Microsoft Excel ™.
© Ethical clearance was obtained from the institutional ethical committee.

Results

We found that the diagnosis of IBD was much more specific than expected with good sensitivity when data was matched between Macroscopy and Microscopy

Conclusion

• It is our standard practice to do colonoscopic biopsies from 7 areas (terminal ileum, cecum, ascending colon, transverse colon, descending colon, sigmoid colon, rectum) of the colon to exclude microscopic colitis which may be missed by the endoscopist or marked as ‘normal’.
• Microscopic findings are considered as ‘Gold standard’ in the diagnosis of IBD and we envisage that it will remain the gold standard in the many next decades to come
• Our data of sensitivity and sensitivity of the microscopic findings inclined the relevance of colonic mucosal biopsies in children with a normal-appearing mucosa and also the need to analyse every segment of the colon to diagnose IBD that may masquerade as “normal” in children which will add burden to the family, society and health care system and more importantly to the child’s quality of life.

References

1. Manfredi, Michael A et al. “Good agreement between endoscopic findings and biopsy reports supports limited tissue sampling during pediatric colonoscopy.” Journal of pediatric gastroenterology and nutrition vol. 58,6 (2014): 773-8.
2. Altamimi, Eyad & Odeh, Yousef & Al-Quraan, Tuka & Mohamed, Elmi & Rawabdeh, Naif. (2022). Diagnostic and therapeutic outcomes of pediatric colonoscopies in Jordanian children. Journal of Pediatric and Neonatal Individualized Medicine. 11.

Clinical Case Summary

Introduction: Leiomyosarcoma (LMS) is a rare mesenchymal tumor, affecting the gastrointestinal tract and subcutaneous soft tissues as the most common locations^1,2,3. Here, we report a case of a primary leiomyosarcoma of the liver, initially misdiagnosed as a hepatocellular carcinoma (HCC) and effectively treated with sorafenib.
Case report: A 69 years old Caucasian man with a HCV-related cirrhosis was hospitalized in May 2021 for an upper gastro-intestinal bleeding from esophageal varices. During the hospitalization, he received a radiological (arterial phase wash-in and portal and delayed venous phases washout) and biochemical (AFP 7,073 ng/mL) diagnosis of a monofocal HCC with neoplastic portal vein thrombosis. Treatment with sorafenib was started in August 2021, and at the first control CT scan a partial response according to mRECIST criteria was demonstrated, with a total normalization of AFP levels. Two months later, following the good response to systemic therapy, the patient underwent right hepatectomy. However, at the histologic evaluation a primary liver leiomyosarcoma was described. Since resection was R1, after this diagnosis, the patients started adjuvant treatment with Pazopanib. Unfortunately, the disease progressed despite various unsuccessful chemotherapy regimens and died in September 2022.
Conclusion: Liver LMS is a rare tumor, rarely taken into consideration in the differential diagnosis of a liver mass. In the case we report, the association with HCV-related cirrhosis, the high levels of AFP and the response to Sorafenib treatment would have hardly put the diagnosis of primary liver LMS in any differential diagnosis list. Here we therefore describe the first case, as far as we are aware, of liver primary LMS expressing high levels of AFP and successfully treated with sorafenib.

References

1. Serrano C, George S. Leiomyosarcoma. Hematol Oncol Clin North Am. 2013;27(5):957-974. doi:10.1016/j.hoc.2013.07.002
2. Metta H, Corti M, Trione N, et al. Primary hepatic leiomyosarcoma--a rare neoplasm in an adult patient with AIDS: second case report and literature review. J Gastrointest Cancer. 2014;45 Suppl 1:36-39. doi:10.1007/s12029-013-9525-3
3. Baek I, Kim JH, Lee MS, et al. Taehan Kan Hakhoe Chi. 2002;8(4):481-185.

Introduction

The Updated Sydney System recommends reporting the severity of both glandular atrophy (GA) and intestinal metaplasia (IM) as two independent parameters. However, the OLGA system assesses both GA and IM together as part of the same entity which should be reported as an average severity. The OLGIM system is based on the IM severity recommended by the updated Sydney system. Thus, the final OLGIM score can be estimated by any clinician. Currently, no system addresses the severity of both GA and IM as they are reported following the updated Sydney recommendation.

Aims & Methods

This study aimed to assess the utility of a new system, OLGIMA (Operative Link on Gastric IM and GA assessment), as a tool to identify patients at higher risk for GC in daily practice.
Consecutive diagnostic UGI endoscopies performed for any indications in patients older than 18 years old were recorded prospectively in 21 Spanish hospitals between April 2021 and July 2023. Protocolized gastric biopsies were taken according to the Updated Sydney consensus. We excluded patients with dysplasia, any malignancy, suspicion of autoimmune chronic atrophic gastritis, and lack of histological data. The severity of both GA and IM was assessed in the antrum (including incisura) and corpus following the updated Sydney system. After that, we considered the most advanced severity (none:0; mild:1; moderate:2; marked:3) provided for any of them in each of the two topographical areas. Then, the OLGIMA staging was done according to the same methodology used by the OLGA and OLGIM systems.

Results

A total of 998 patients were included. The median age was 57 (IQR 46 - 67), and 64% were women. Hp infection was identified in 334 (35%) patients (19% active infection and 16% eradicated). GA was identified in 192 (19.2%) patients which was limited to the antrum in 113 (11.3%) cases and extensive in 79 (7.9%). IM was identified in 159 (15.9%) patients which was limited to the antrum in 114 (11.4%) cases and extensive in 45 (4.5%). According to IM severity, 27 (2.7%) patients were OLGIM III/IV. According to GA severity, 22 (2.2%) patients were significantly extensive. The OLGIM system would have missed 12 (1.2%) patients with GA at higher risk. Considering both criteria, we would have detected 39 (3.9%) patients at higher risk in total (17 OLGIM III-IV, 12 extensive significative GA, and 10 both OLGIM III-IV and extensive significative GA). The new OLGIMA system categorized all 39 (3.9%) patients, OLGIM III-IV and significantly extensive GA, in the high-risk group (OLGIMA III/IV).

Conclusion

The new OLGIMA system (based on the severity of IM and GA recommended by the updated Sydney system) was able to detect patients at higher risk including all cases of OLGIM III/IV and also with advanced GA. The OLGIMA staging is much simpler and it can be estimated by any clinician regardless of whether the biopsy from incisura was taken.

References

Rugge M, Meggio A, Pennelli G et al. Gastritis staging in clinical practice: the OLGA staging system. Gut. 2007;56:631-6
Capelle LG, de Vries AC, Haringsma J et al. The staging of gastritis with the OLGA system by using intestinal metaplasia as an accurate alternative for atrophic gastritis. Gastrointest Endosc. 2010;71:1150-8
Pimentel-Nunes P, Libânio D, Marcos-Pinto R et al. Management of epithelial precancerous conditions and lesions in the stomach (MAPS II): European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter and Microbiota Study Group (EHMSG), European Society of Pathology (ESP), and Sociedade Portuguesa de Endoscopia Digestiva (SPED) guideline update 2019. Endoscopy. 2019;51:365-388.

Introduction

Low-code/no-code (LCNC) applications are under-utilised as clinician-built solutions for daily hospital-based tasks. Waikato Hospitals endoscopy unit in Hamilton, New Zealand, on average receives five to twelve acute endoscopy requests per day. Prior to December 2021 all inpatient endoscopy requests for conditions such as gastrointestinal bleeding, were made on handwritten paper and faxed to the endoscopy unit. Following this the co-ordination and triage of multiple referrals occurred onsite from a single physical board. This created problems such as forms being lost, handwriting illegible and co-ordination and communication inefficient. Environmental sustainability was also a major concern regarding paper wastage.

Aims & Methods

We aimed to develop a referral and management system for acute endoscopy requests using LCNC technology. This would be built and maintained by the endoscopy staff and tailored to clinical and administrative needs. We used the Microsoft Power Platform, Power Automate and Power Apps, to develop this clinician-built triage and management system, alongside an electronic referral request for acute endoscopy from Clinical Work Station™ (Waikato Hospitals electronic medical records system). The system was developed by a Gastroenterology Trainee with experience in LCNC systems, and was developed with the endoscopy staff. The electronic referral system went live on 6th of December 2021.

Results

From December 2021 to August 2022, our clinician-built system had 4512 visits with up to 44 unique users monthly using the Microsoft PowerApp through mobile and desktop, either directly or through Microsoft Teams. The Microsoft Power App recorded 1201 new endoscopy referrals, of which 1007 (84%) endoscopies were completed, 56 (5%) duplicate referrals, 17 (1%) triaged to outpatient endoscopy and 111 (10%) declined or cancelled back to the referrer. 1177 (98%) referrals utilised the electronic notifications setting between clinicians, nursing and administration staff using push notifications, minimising the need for face-to-face contact and physically meeting. The system eliminated paper waste, while also optimised patient care by real time co-ordination of referrals and improved documentation when making or changing triage decisions. Prior to December 2021 there were 15 steps from the patient presenting to hospital with a gastrointestinal bleed to having their endoscopy completed, now the process is shortened to seven steps, with instant upload of requests upon submission of an endoscopy request and real-time tracking. 10 endoscopy staff including 2 doctors and 6 endoscopy nurse co-ordinators provided positive feedback and support for its ongoing use during staff surveys.

Conclusion

The LCNC system we have developed is clinician focused, modified for our needs and is built on current Microsoft 365™ licencing, which does not incur extra costs to our hospital, and allows integration into Microsoft Outlook™ and Microsoft Teams™. In the short time our system has been online, it has demonstrated efficiency, sustainability, and safety for patient care with high levels of clinician satisfaction and has potential to be integrated to other hospitals with similar Microsoft 365™ licencing.

Introduction

Treatment targets of ulcerative colitis (UC) have evolved to include not only endoscopic but also histologic remission. However, the concept of histological activity is still in its early days. We aimed to capture the attitudes towards UC histology and the uptake of standardized reporting of endoscopy and histology of UC in daily practice.

Aims & Methods

We conducted a cross-sectional survey of physicians involved in the care of IBD worldwide. The survey included 21 questions divided into 3 sections. The first recorded demographics, specialty, and level of experience of participants; the second covered clinical practices and attitudes towards the use and reporting of endoscopy, and the third of histology.

Results

Participants: In total 359 physicians, from 60 countries (54.4% Europe, 24.4% Asia, 12.9% South America, 3.7% North America, 3.2% Africa, and 1.4% Oceania) responded; 87% were gastroenterologists, the remainder other specialists involved in the care of IBD. The majority practiced in academic hospitals (54.5%) or tertiary centers (22.1%), and only around one-fifth worked in secondary hospitals (12.8%) or local practices (8.1%).
Endoscopy: When performing endoscopy in quiescent UC, 72.1% of respondents reported taking biopsies also to assess microscopic activity, while 16.8% only for dysplasia detection, and 10.4% just in case of suspicious lesions; the average number of biopsies was 10.8 (SD 7.34, range 0 to 36). In the case of active UC, the percentage of operators collecting biopsies increased to 93.6%.
Endoscopy reports included a validated score in 91.9% of cases. Mayo was nearly always used (90%), with a large difference from the second most common score UCEIS (26.5%); other indices accounted for 1.7%. Of note, except for 1 respondent, all scores different from Mayo were used in addition to, and not instead of, Mayo. When restricting the analysis to participants working in high-volume centers (>500 UC patients cared for per year) all but one (117/118) reported using the Mayo score to grade endoscopic activity, and 32% (38/117) used also other scores in addition to Mayo, mainly UCEIS.
Histology: Centers represented in the survey were roughly equally split between those with a pathologist dedicated to IBD (46.2%) and those without (51%). UC histology was used by nearly all respondents (90.5%) for initial diagnosis, 72% to monitor disease course, 62.4% to determine microscopic extension, 59.9% to confirm deep remission when considering stopping treatment, and 42.3% to increase/optimize treatment. Nevertheless, 77.2% of participants reported that standard histological indices were not routinely available, although 21.7% of these used scores in selected cases, such as clinical trials or research. Among those who used (or worked in a center that used) standard scores (160/357) the choice of which index was mixed: 64.4% (103/160) used the Nancy index, followed by Geboes 31.9% (51/160), and Robarts 20.6% (33/160), a minority applied other scores.
The majority of respondents welcomed as useful or very useful an artificial intelligence system to automate scoring of endoscopy (69%) or histology (73%).

Conclusion

UC histology reports are less standard than endoscopy ones. Most physicians consider histological activity useful when managing UC and would welcome artificial intelligence systems to automate endoscopic and histological scoring.

Disclosure

OMN has served as a speaker for Janssen, Ferring, Takeda, Pfizer, Fresenius Kabi
MI has received research grants and equipment loans from Pentax USA, Olympus, and Fujifilm; is partially funded by NIHR Birmingham Biomedical Research Centre at the University Hospitals Birmingham NHS Foundation Trust and the University of Birmingham.
LPB reports personal fees from Galapagos, AbbVie, Janssen, Genentech, Ferring, Tillots, Celltrion, Takeda, Pfizer, Index Pharmaceuticals, Sandoz, Celgene, Biogen, Samsung Bioepis, Inotrem, Al-lergan, MSD, Roche, Arena, Gilead, Amgen, BMS, Vifor, Norgine, Mylan, Lilly, Fresenius Kabi, OSE Immunotherapeutics, Enthera, Theravance, Pandion Therapeutics, Gossamer Bio, Viatris, Thermo Fisher; grants from Abbvie, MSD, Takeda, Fresenius Kabi; stock options: CTMA.
SG has served as consultant, Steering committee member, Advisory Board Member and Drug Monitoring committee member for Janssen, Pfizer, Takeda, Abbvie, BMS, Gilead, Galapagos, Celltrion, Eli Lilly, Ferring.
SD has served as a speaker, consultant and advisory board member for Schering Plough, Abbott (AbbVie) Laboratories, Merck and Co, UCB Pharma, Ferring, Cellerix, Millenium Takeda, Nycomed, Pharmacosmos, Actelion, Alfa Wasserman, Genentech, Grunenthal, Pfizer, AstraZeneca, Novo Nordisk, Vifor and Johnson and Johnson.

Remaining authors declare no relevant conflict of interest.

Introduction

Since the report of Shaker in 1994, transnasal esophagogastroduodenoscopy (T-EGDS) has been reported worldwide as one technique to facilitate comfortable procedures avoiding sedation. From 1996 in our Centre, we routinely use this technique in all the patients for diagnostic and selected operative EGDS. This approach is also suitable for the placement of percutaneous endoscopy gastrostomy (PEG) but in the published papers it has been performed only when conventional upper gastrointestinal endoscopy was unusable (dysphagic patients with neurological disease or with stenosis and/or occlusion of the mouth or pharynx). On the contrary, since 2000 we have routinely used the transnasal approach for all patients requiring PEG, reserving the oral technique when the transnasal access route is impossible.

Aims & Methods

We performed a retrospective analysis of all patients who underwent PEG placement between January 2000 and March 2023 in the Unit of Gastroenterology of San Camillo De Lellis Hospital, Rieti, Italy, in order to demonstrate the feasibility and safety of T-PEG placement in routine practice. We used ultrathin gastroscope through a nostril after assessment and lubrification, and the pull technique was used for tube placement.

Results

PEG placement was required for 256 consecutive patients (male 49.4%; female 51.6%), the average age was 79 years, within a range from 26 to 104 years. Transnasal approach was used in 162 patients (nasal group: 63.3%) while oral approach was used in 94 (oral group: 36.7%). The failure of transnasal approach was related to impossibility of nasal intubation due to narrow nasal passages or to inability to transilluminate the stomach. In these cases we needed transoral route. 14 patients underwent transoral PEG placement due to unavailability of transnasal gastroscope. The duration of the procedures was similar in both approaches (12 ±3 minutes oral vs 13±4 minutes nasal).
The most common indications for PEG insertion were neurologic disorders (n=132, 51.6 %), cerebrovascular accident (n=73, 28.5 %), esophageal cancer or head and neck cancer (n=18, 7 %), other pathologies (n=33, 12.9 %). 167 procedures were performed without sedation: 77.8 % ( n= 130) in the nasal group and only 22.1% (n=37) in the oral group. Outpatient regimen PEG placement was also significantly higher in trans nasal group (79 % vs 58 % oral group). We registered 3 major complications, 1 in oral group and 2 in nasal group (one necessitated surgery). No procedure-related death was registered. There were no unplanned re-admissions of outpatients discharged from the gastroenterology unit for procedure-related complications.

Conclusion

The more than twenty years’ experience of our center demonstrates that the transnasal approach is safety, feasible and could be routinely used in daily endoscopic practice for PEG placement. The minimally invasive technique therefore reserves sedation to a few selected cases to reduce costs, improve logistic organization and avoid anesthesia related complications.

References

1. Campo R, Montserrat A, Brullet E. Transnasal gastroscopy compared to conventional gastroscopy: a randomized study of feasibility, safety, and tolerance. Endoscopy. 1998 Jun;30(5):448-52.
2. Schuldt AL, Kirsten H, Tuennemann J, Heindl M, van Bommel F, Feisthammel J, Hollenbach M, Hoffmeister A. Necessity of transnasal gastroscopy in routine diagnostics: a patient-centred requirement analysis. BMJ Open Gastroenterol. 2019 Apr 14;6(1):e000264.
3. Dumortier J, Lapalus MG, Pereira A, Lagarrigue JP, Chavaillon A, Ponchon T. Unsedated transnasal PEG placement. Gastrointest Endosc. 2004 Jan;59(1):54-7.
4. Dumortier J, Napoleon B, Hedelius F, Pellissier PE, Leprince E, Pujol B, Ponchon T. Unsedated transnasal EGD in daily practice: results with 1100 consecutive patients. Gastrointest Endosc. 2003 Feb;57(2):198-204
5. Preiss C, Charton JP, Schumacher B, Neuhaus H. A randomized trial of unsedated transnasal small-caliber esophagogastroduodenoscopy (EGD) versus peroral small-caliber EGD versus conventional EGD. Endoscopy. 2003 Aug;35(8):641-6.