Introduction

Despite the progress in advanced therapies (AT) for ulcerative colitis (UC), selecting a second-line treatment after failure remains challenging. Recent guidelines recommend Ustekinumab (UST), Tofacitinib (TOFA), or Upadacitinib (UPA) as high-efficacy options after prior AT failure. However, no real-world studies have compared all three therapies.

Aims & Methods

Retrospective multicenter study (8 centers) of UC patients who failed ≥1 advanced therapy. Patients were stratified into UST, TOFA, or UPA groups and assessed at 16 and 52 weeks. The primary outcome was steroid-free clinical remission (SFCR) based on the Patient Reported Outcomes-2. Secondary outcomes included biochemical remission (fecal calprotectin ≤ 250 µg/g) and endoscopic remission (Mayo Endoscopic Subscore=0). Time to remission was assessed using Cox regression analysis. A subanalysis was performed including only second-line use after anti-TNF failure. Multivariate analysis was performed, adjusted for duration of disease, extent and number of prior therapies.

Results

We evaluated 259 cases [54.4% (n=141) female; diagnostic age 32.3 ± 15.1 years] who initiated UST (n=105; 40.5%), UPA (n=87; 33.6%) or TOFA (n=67; 25.9%). The groups were similar in disease duration (UST: 11.6 ± 8.0; UPA: 9.8 ± 6.4; TOFA: 10.4 ± 5.4 years) and 49.8% (n=129) had failed ≥2 previous AT
At week 16, UPA showed higher SFCR compared to UST (OR 2.1; p=0.014) and TOFA (OR 2.1; p=0.040), with no difference at week 52. Biochemical remission was higher with UPA at week 16 vs UST (OR 2.3; p=0.015) and TOFA (OR 2.1; p=0.039) and at week 52 vs UST (OR 4.7; p=0.010) and TOFA (OR 4.6; p=0.013). At week 16, endoscopic remission was higher with UST (OR 3.5; p=0.036) and UPA (OR 3.1; p=0.041) compared to TOFA; and at week 52, UPA was associated with higher endoscopic remission vs UST (OR 3.6; p=0.036).
In Cox regression, UPA achieved earlier biochemical remission than UST (HR 1.9; p<0.001) and TOFA (HR 1.8; p=0.011). JAK inhibitors led to earlier endoscopic remission than UST (vs UPA: HR 3.2; p<0.001; vs TOFA: HR 1.4; p=0.002).
In the subanalysis, UPA as second-line therapy demonstrated higher SFCR than TOFA (OR 3.6; p=0.035) and higher endoscopic remission at week 52 than TOFA (OR 12.0; p=0.017), and trend-wise compared to UST (OR 4.5; p=0.090).

Conclusion

Even though all three medication demonstrated high efficacy in bio-exposed UC patients, UPA achieved better results in this real world study.

References

Singh, Siddharth, et al. "AGA living clinical practice guideline on pharmacological management of moderate-to-severe ulcerative colitis." Gastroenterology 167.7 (2024): 1307-1343.

Clinical Case Summary

The endoscopic removal of polyps located at the appendiceal orifice is a challenge, particularly when extending inside the appendiceal lumen, due to its anatomic difficulty and risk of complications.
The endoscopic full-thickness resection (FTR) technique has become an non-surgical option for these lesions but with a non negligible risk of appendicitis.
With the present case we explore an alternative technique.
A 75-year-old man with iron deficiency anemia underwent upper digestive endoscopy and colonoscopy.
The upper digestive endoscopy was normal.
In the colonoscopy angiectasias were found in the cecum and multiple polyps in the left colon (the largest measuring 30 mm). The inspection of the appendix revealed an intra-appendiceal orifice lesion (Image A).
Only after inversion of the appendix it was possible to accurately assess the lesion: an approximately 15 mm sessile polyp (Images B, C).
We applied argon plasma for ectasias ablation and removed the left colon polyps by endoscopic mucosal resection.
Intra-appendiceal orifice polyp resection was performed underwater with a diathermic loop (Image D), with no immediate or late complications.
Histology revealed a sessile serrated adenoma with low-grade dysplasia.
The described technique, being a simpler, faster and cheaper option than the endoscopic-FTR is a valid and a cost effective one.

Introduction

Biliary and gastric outlet obstruction (GOO) are common complications in patients with pancreatic cancer, often delaying essential cancer treatments. While endoscopic ultrasound-guided
gastroenterostomy (EUS-GE) has been shown to be superior to duodenal self-expandable metal stents (dSEMS) for managing GOO, the optimal strategy for biliary drainage (BD) in this setting remains unclear. Specifically, there is no consensus on whether to prefer EUS-guided choledochoduodenostomy (EUS-CDS) or EUS-guided hepaticogastrostomy (EUS-HGS).

Aims & Methods

We conducted a systematic review and meta-analysis to identify the optimal biliary drainage approach in patients undergoing EUS-GE for concomitant GOO and biliary obstruction. We searched Medline, Scopus, and EMBASE up to February 2025. Studies were included if they reported outcomes of EUS-CDS or EUS-HGS in patients with biliary obstruction and concomitant GOO
treated by EUS-GE. Pooled outcomes included technical and clinical success, stent dysfunction, and adverse events, analyzed using a random-effects model. Results were reported as relative risks (RRs) with 95% confidence intervals (CIs).

Results

Five studies met inclusion criteria, comprising 128 patients (female = 45.5%; mean age range 63.0–73.0 years), with 61 undergoing EUS-CDS and 67 undergoing EUS-HGS. Four studies were conducted in Europe and one in the United States; one study was prospective. Technical success rates were similar between groups (RR 0.96, 95% CI 0.83–1.11; I² = 0%; EUS-CDS 94.5% vs EUS-HGS 96.4%), as were clinical success rates (RR 1.04, 95% CI 0.92–1.19; I² = 0%; EUS-CDS 96.5% vs EUS-HGS 89.1%). However, the risk of stent dysfunction was significantly higher in the EUS-CDS group compared to EUS-HGS (RR 4.42, 95% CI 1.71–11.43; I² = 0%; EUS-CDS 45.1% vs EUS-HGS 10.9%). The incidence of procedure-related adverse events was comparable between the two approaches (RR 1.14, 95% CI 0.24–5.50; I² = 40.8%; EUS-CDS 10.7% vs EUS-HGS 16.0%).

Conclusion

This meta-analysis suggests that both EUS-CDS and EUS-HGS are similarly safe and effective for managing malignant biliary obstruction in the setting of concomitant GOO. However, EUS-CDS is associated with a more than four-fold increase in the risk of stent dysfunction, which may result in delays to critical cancer treatments.

Disclosure

None

Introduction

EUS-guided gastroenterostomy (EUS-GE) is increasingly used in the management of Gastric Outlet Obstruction. However, significant variability exists in technical choices which might account for heterogeneous clinical outcomes. The aim of this Delphi methodology was to address open questions and establish a consensus on best practices to gather expert opinions on key aspects of EUS-GE.

Aims & Methods

A panel of 25 international leading experts in EUS-GE was invited to revise literature around the technique. A Delphi process was conducted over three rounds, with each round involving anonymous voting on 29 predefined statements, using a 5-point Likert scale (1: strongly disagree – 5: totally agree). Responses were analysed through Medians [Interquartile Ranges], with pre-defined thresholds for approval, revision or discard of the statement. Statements reaching final consensus were graded based on the strength of agreement, defined as the proportion of responses rated 4 or 5.

Results

Response rate was 88% in Round 1 and 100% in Round 2 and 3. Among 29 statements, eight were approved at Round 1, eighteen at Round 2 and four at Round 3, while two were ultimately rejected.
There was early and excellent agreement (>95%) on the need of fluoroscopy for EUS-GE, the need for electrocautery-enhanced Lumen Apposing Metal Stent (LAMS), and the preference for free-hand release. All panellists agreed that endoscopists performing EUS-GE should be familiar with management of Adverse Events (AEs) such as bleedings or perforations. After discussion, excellent agreement was obtained for the management of AEs (misdeployments and bleedings) and LAMS dysfunctions.
Final Strong agreement (>90%) was reached for preferred patient positioning, the required sedation and the preference for saline solution for jejunal distention.
Extensive discussion with final Moderate agreement (>80%) was reached on the use of dye, the preference for catheter-assisted EUS-GE instead of endoscope- or needle-directed instillation, the typical location for EUS-GE and the operative space required for LAMS release.
Statements on the use of contrast and the choice between WEST and EPASS techniques were removed due to lack of agreement.

Conclusion

Despite technical differences (such as the preference of a jejunal catheter or a double-balloon catheter) most EUS-GE experts agree on key technical principles, providing valuable guidance on the standardization of EUS-GE in clinical practice. Conversely, certain topics showed limited agreement, identifying future research priorities in the field of EUS-GE.

Clinical Case Summary

Introduction: Dieulafoy lesions account for less than 2% of gastrointestinal bleeds, and only 20% of these occur outside the stomach. We present a rare case of a bleeding ampullary Dieulafoy lesion with technical difficulties in management, starting with a standard forward-viewing gastroscope, subsequent use of a side-viewing duodenoscope, and eventually endoscopic retrograde cholangiopancreatography (ERCP) and stenting to allow for safe haemostasis with argon plasma coagulation (APC).
Case report: A 56-year-old male was admitted with pneumonia and fluid overload in the context of end-stage renal disease from poorly controlled diabetes mellitus and hypertensive nephrosclerosis on regular haemodialysis. He was on dual anti-platelet therapy with aspirin and ticagrelor for a recent cardiac stent.
Five days into his admission he was noted to have melena with a haemoglobin drop from 87 g/L to 56 g/L, with a urea rise of 23.9 mmol/L from a baseline of 11.0 mmol/L.
Subsequent gastroscopy revealed active bleeding from the major ampulla without any underlying ulcer or tumour, superior to the biliary orifice, consistent with an ampullary Dieulafoy lesion. The duodenoscope was then introduced for a better view and access to the major ampulla. APC was attempted at 0.8 L/min at 30 Watts due to the size and location, but haemostasis was unsuccessful.
The decision was made to proceed to ERCP and biliary stenting to prevent complications from heat injury to the bile duct and possible pancreatitis. A 7 Fr by 4 cm double pigtail biliary plastic stent was placed into the common bile duct. APC was re-applied at 0.8 L/min at 30 Watts at the bleeding spot with successful haemostasis.
Discussion: This case report aims to highlight the rare occurrence of duodenal ampullary Dieulafoy lesions and the need for prompt recognition and use of resources such as side-view duodenoscopy and ERCP for safe therapeutic management.

Disclosure

None

Clinical Case Summary

Introduction: The most common complications of ERCP include acute pancreatitis, post-sphincterotomy bleeding, and intestinal perforation. Traumatic arterio-biliary fistulas, although rare, have been reported following manipulation. This case presents severe haemorrhage secondary to an arterio-biliary fistula.
Case Report: A 61-year-old male, chronic alcoholic with chronic liver disease (BCLC-B) and distal bile duct stricture of filarial aetiology, was admitted for biliary stent replacement. Post-procedure, the patient developed worsening clinical parameters, including abdominal pain, leucocytosis, and elevated cholestasis markers. Imaging revealed the proximal end of the stent was in the cystic duct, requiring a second ERCP for repositioning.
The patient's condition deteriorated with severe acute cholangitis, haemorrhagic rectal bleeding, and haemodynamic instability. CT showed further biliary dilatation and haematic content within the bile ducts. A third ERCP was performed to remove clots and place a covered metallic stent to control the bleeding. Despite this, haemorrhage persisted. CT-angiography revealed a 9 mm pseudoaneurysm from the pancreaticoduodenal arcade and pancreatic artery (Figure 1). Selective embolisation was successful (Figure 2), with follow-up confirming no further aneurysm filling (Figures 3 and 4).
Discussion: Arterio-biliary fistulas are typically iatrogenic or traumatic, often following biliary or hepatic procedures like liver biopsy or cholecystectomy. Post-ERCP incidence is rare, with only three reported cases. Diagnosis requires high clinical suspicion and angiography. Fistulas can cause pseudoaneurysms, which may lead to haemobilia, presenting as gastrointestinal bleeding. Management is multidisciplinary; conservative treatment is suitable for small, non-bleeding fistulas, while endoscopic or radiological interventions are used for severe cases. Early intervention is key to favourable outcomes.

References

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2. Berry R, Han J, Mohit Girotra, Tabibian JH. Hemobilia: Perspective and Role of the Advanced Endoscopist. 2018 Jul 12;2018:1–12.
3. Delayed Massive Hemobilia After Biliary Stenting. Endoscopy. 2003 Nov;35(11):976–7.
4. Siu, W. T., Chau, C. H., Ka Bo Law, B., Yau, K. K., Luk, Y. W., & KaWah Li, M. Non-operative management of endoscopic iatrogenic haemobilia: case report and review of literature. Acta gastro-enterologica Belgica. 2005;68(4): 428–431.
5. Panno, C., Gutiérrez, S. C., Echeverría, R., Garbe, C., Milocco, M., Ianniccillo, H., Valenzuela, M., Cubilla, A., Alvarez, F., & Alvarez, E. Hemobilia secundaria a pseudoaneurisma de la arteria hepática [Hemobilia secondary to hepatic artery pseudoaneurysm]. Acta gastroenterologica Latinoamericana. 2015;45(2):133–136.