Introduction

Faecal urgency (FU) is a frequently encountered yet frequently underappreciated symptom experienced by many individuals suffering from inflammatory bowel disease (IBD)^1,2. In cases of ulcerative colitis, the presence of FU is relatively easy to comprehend, as inflammation typically involves the rectum and left-sided colon, which are closely linked to urgency symptoms. However, in patients diagnosed with Crohn’s disease (CD), where lesions are more commonly found in more proximal areas of the gastrointestinal tract — such as the ileum or the right colon while the distal regions like the left colon and rectum often remain unaffected, the emergence of FU becomes more difficult to explain.

Aims & Methods

The objective of this study was to evaluate and compare the prevalence and intensity of FU in CD patients with proximal versus distal involvement, using the splenic flexure as the dividing point. The study also aimed to explore associations between FU and markers of disease activity, work-related productivity, quality of life (QoL), and psychological symptoms such as anxiety and depression.
A cross-sectional study was carried out at a tertiary care centre, involving a sample of CD patients who completed a comprehensive survey between July and September 2024. FU severity was measured on a numeric rating scale ranging from 0 to 10, with scores of 0 or 1 indicating absence of FU³. Participants also completed the Work Productivity and Activity Impairment Questionnaire (WPAI-GH), the Short Inflammatory Bowel Disease Questionnaire (SIBDQ), and the Hospital Anxiety and Depression Scale (HADS). Data analysis was conducted using SPSS Statistics software, version 26®.

Results

A total of 158 patients were included in the study, with a mean age of 42.1 ± 1.3 years; 88 individuals (55.7%) were female. Among the participants, 109 (69.0%) reported experiencing faecal urgency (FU). Proximal disease was present in 97 patients (61.4%), while 61 patients (38.6%) had distal involvement. Of those, 69 individuals (71.1%) with proximal disease and 40 (65.6%) with distal disease reported FU. However, distal involvement was not significantly associated with the presence of FU symptoms (OR = 0.77; 95% CI [0.39–1.54]; p = 0.46), nor with symptom severity, even in the subset of patients with documented rectal involvement (n = 24; 39.3%). No significant correlation was found between the presence or severity of FU and markers of disease activity, including faecal calprotectin, C-reactive protein, endoscopy, histology, abdominal ultrasound or clinical indices. In contrast, the severity of FU showed a weak but statistically significant positive correlation with elevated anxiety symptoms (ρ = 0.32; p = <0.001) and depressive symptoms (ρ = 0.31; p = <0.001). Only FU, not anxiety or depression, showed to be associated with overall work productivity loss (β = 2.48 [0.55-4.40]; p = <0.001). Higher scores of FU, anxiety and depression were all associated with poorer QoL (β1 = -1.09 [-1.50--0.68]; β2 = -0.61 [-1.00--0.23]; β3 = -1.32 [-1.71--0.92]; p = <0.001).

Conclusion

In this study, the occurrence of FU in CD was not associated with the location of disease involvement or markers of disease activity. Instead, FU showed a stronger relationship with psychological factors, specifically symptoms of anxiety and depression. These findings suggest that managing FU may require therapeutic strategies beyond conventional immunomodulatory treatments⁴.

References

1. Ha C, Naegeli AN, Lukanova R, Shan M, Wild R, Hennessy F, Jyothi Kommoju U, Potts Bleakman A, Hunter Gibble T. Rectal Urgency Among Patients With Ulcerative Colitis or Crohn's Disease: Analyses from a Global Survey. Crohns Colitis 360. 2023 Sep 25;5(4):otad052. doi: 10.1093/crocol/otad052. PMID: 37928613; PMCID: PMC10622170.
2. Dawwas GK, Jajeh H, Shan M, Naegeli AN, Hunter T, Lewis JD. Prevalence and Factors Associated With Fecal Urgency Among Patients With Ulcerative Colitis and Crohn's Disease in the Study of a Prospective Adult Research Cohort With Inflammatory Bowel Disease. Crohns Colitis 360. 2021 Jul 8;3(3):otab046. doi: 10.1093/crocol/otab046. PMID: 36776663; PMCID: PMC9902261.
3. Dubinsky MC, Clemow DB, Hunter Gibble T, Li X, Vermeire S, Hisamatsu T, Travis SPL. Clinical Effect of Mirikizumab Treatment on Bowel Urgency in Patients with Moderately to Severely Active Ulcerative Colitis and the Clinical Relevance of Bowel Urgency Improvement for Disease Remission. Crohns Colitis 360. 2022 Dec 13;5(1):otac044. doi: 10.1093/crocol/otac044. PMID: 36777368; PMCID: PMC9802448.
4. Caron B, Ghosh S, Danese S, Peyrin-Biroulet L. Identifying, Understanding, and Managing Fecal Urgency in Inflammatory Bowel Diseases. Clin Gastroenterol Hepatol. 2023 Jun;21(6):1403-1413.e27. doi: 10.1016/j.cgh.2023.02.029. Epub 2023 Mar 9. PMID: 36906079.

Clinical Case Summary

Case Description: A 62-year-old woman from Príncipe, residing in Portugal for 2 months, presented to the emergency department with fever and abdominal pain for one day. She had no acholic stools or dark urine. Her medical history included type 2 diabetes, obesity and dyslipidemia with no pharmacological treatment. Laboratory tests revealed neutrophilic leukocytosis and cholestasis (leukocytes 21.38×10⁹/L;AST 699 IU/L;ALT 527 IU/L;ALP 207 U/L;GGT 486 U/L;Total Bilirubin 1.60 mg/dL; Direct Bilirubin 1.17 mg/dL; CRP 3.2 mg/L). CT showed a thickened, distended gallbladder with radiodense endoluminal material and a dilated common bile duct (CBD),10 mm, without obstruction. The diagnosis of acute lithiasic cholangitis and cholecystitis was established. The patient was started on intravenous fluids and antibiotics and an endoscopic retrograde cholangiopancreatography (ERCP) was scheduled within 72 hours. After 48 hours, she remained in pain and tachycardic. Repeat laboratory tests indicated coagulopathy (INR 1.64), prompting urgent biliary drainage. ERCP revealed a 30 cm Ascaris lumbricoides in the duodenum, which was removed using forceps. A single dose of albendazole was administered. Cholangiography showed a normal CBD but a gallbladder with spherical content. A 7Fr×5cm plastic biliary stent was placed. One week later, a follow-up ERCP with sphincterotomy confirmed bile duct clearance, and the stent was removed. The patient was discharged after 9 days. One month later, the patient underwent cholecystectomy and the specimen report revealed foci of low-grade intraepithelial neoplasia.
Conclusion: In endemic regions, both biliary lithiasis and hepatobiliary parasitic infections are common. Imaging findings may be similar, but the absence of CBD stones and the presence of Ascaris near the papilla strongly suggest transient biliary obstruction due to the parasite, highlighting the importance of epidemiological factors in the evaluation of acute cholangitis.

References

Figure 1 (First ERCP): Duodenoscopy identifies a long, cylindrical parasite in the second portion of the duodenum, adjacent to the papilla.
Figure 2 (First ERCP): Cholangiography shows the CBD and intrahepatic bile ducts without filling defects. The gallbladder contains spherical content.
Figure 3 (Second ERCP): Cholangiography shows no abnormalities in the CBD or intrahepatic bile ducts. Sphincterotomy was performed with no biliary content drainage.

Disclosure

Nothing to declare

Introduction

Transjugular intrahepatic portosystemic shunt (TIPS) is a well-established procedure frequently employed to manage portal hypertension associated conditions such as variceal bleeding, ascites, and hydrothorax. However, despite its benefits, TIPS placement is frequently complicated by post-TIPS hepatic encephalopathy (HE), a condition that can significantly impact patient outcomes and quality of life. Currently, there is a lack of consensus and robust evidence regarding the optimal prophylactic treatments for post-TIPS HE. There is a recommendation suggesting the use of rifaximin, which is based solely on a single randomized controlled trial^1,2. Thus, more data are needed to assess the efficacy of prophylactic therapies in a real-world clinical setting.

Aims & Methods

This work aims to compare the efficacy of different prophylactic treatments (lactulose, rifaximin or both) and identify predictive factors for post-TIPS HE.
A retrospective study was conducted at a tertiary TIPS referral centre, including all adult patients who undergone TIPS placement between January/2021 and June/2024. Clinical records were reviewed to collect demographic data, prior decompensations, analytical results, medication and episodes of post-TIPS HE. A minimum of 6 months of follow-up was required. Statistical analysis was performed using SPSS Statistics version 26®.

Results

We included 83 patients, most of them male (n=69;83.1%) with a mean age of 60.1±1.3 years old. Most patients had alcoholic liver disease (n=58; 69.9%), followed by metabolic dysfunction and alcohol-related liver disease (n=6;7.2%). Prior to the procedure 22 (26.5%) patients had previous episodes of HE: 12 (14.5%) were medicated with lactulose, 2 (2.4%) with rifaximin and 8 (9.6%) with both. The remaining 61 (73.5%) had no previous medication. The primary indications for TIPS placement were variceal haemorrhage (n=50; 60.2% [pre-emptive n=21;42.0%]) and refractory ascites or hepatic hydrothorax (n=27;32.5%). The mean pre-TIPS and post-TIPS direct portal pressure were 31.0±0.9 mmHg and 22.2±0.7 mmHg, respectively. After TIPS placement 19 (22.9%) were discharged with lactulose, 3 (3.6%) with rifaximin, 20 (24.1%) with both and 41 (49.4%) with no medication. The mean follow-up time after TIPS placement was 22.3±2.0 months. Twenty-five (30.1%) patients had post-TIPS HE and there were no differences between therapeutic strategies in preventing such episodes (lactulose: OR 2.6 (95%CI 0.7-9.2) p-value 0.14; rifaximin: OR 1.1 (95%CI 0.1-19.0) p-value 0.94; both OR 2.4 (95%CI 0.7-8.2) p-value 0.15). Those discharged with no medication had less post-TIPS HE (OR 0.2 (95%CI 0.1-0.6) p-value 0.008), although these had also less pre-TIPS HE (p-value 0,046). Previous variceal haemorrhage (OR 3.2 (95%CI 1.0-9.9) p-value 0.046) and lower glomerular filtration rate (OR 0.98 (95%CI 0.96-0.99) p-value 0.03) were associated with higher risk for post-TIPS HE.

Conclusion

Our study found no significant differences between prophylactic treatments for post-TIPS HE. Notably, patients who did not receive prophylaxis had lower incidence of post-TIPS HE, although they also had fewer pre-TIPS episodes of HE. This raises questions about the universal application of these treatments and suggests the need for a more individualized approach. The identification of risk factors such as a history of variceal haemorrhage and lower glomerular filtration rate may guide treatment decisions, emphasizing the need for tailored management strategies. Future studies with larger sample sizes and multicentre participation are needed to refine prophylactic recommendations.

References

1. Bureau C, Thabut D, Jezequel C, Archambeaud I, D’Alteroche L, Dharancy S, et al. The use of rifaximin in the prevention of overt hepatic encephalopathy after transjugular intrahepatic portosystemic shunt: a randomized controlled trial. Ann Intern Med. 2021;174:633-40;
2. Lee EW, Eghtesad B, Garcia-Tsao G, Haskal ZJ, Hernandez-Gea V, Jalaeian H, Kalva SP, Mohanty A, Thabut D, Abraldes JG. AASLD Practice Guidance on the use of TIPS, variceal embolization, and retrograde transvenous obliteration in the management of variceal hemorrhage. Hepatology. 2024 Jan 1;79(1):224-250.

Introduction

Anastomotic leaks and fistulae following upper gastrointestinal (GI) surgery remain a serious clinical challenge, carrying high morbidity and mortality. Endoscopic vacuum therapy (EVT) has emerged as a promising minimally invasive treatment option for managing these complications. This study aimed to assess the efficacy and safety of EVT for postoperative anastomotic leaks in a high-volume tertiary referral center.

Aims & Methods

We conducted a retrospective analysis of all patients treated with EVT for anastomotic leakage following upper GI surgery between January 2022 and January 2025. The primary outcome was EVT success, defined as complete leak closure confirmed through both endoscopic and radiologic assessment. Secondary outcomes included procedure-related adverse events and all-cause mortality.

Results

Twenty-four patients were included (79.2% male; mean age: 64 ± 12 years). Of these, 16 patients underwent oesophagectomy and 8 total gastrectomy; only two surgeries were performed for benign conditions. EVT achieved leak closure in 20 patients (87%). One patient died due to hemorrhagic shock from a hepatic artery pseudoaneurysm, unrelated to EVT.
Among successful cases, the mean duration of EVT was 30 ± 19 days, with a median of four sponge exchanges (IQR = 5). Median hospital stay was 52 days (IQR = 41). EVT failure occurred in three patients, all of whom had cancer-related surgeries and defect sizes exceeding 30 mm. In these cases, adjunctive endoscopic treatment with self-expanding metallic stents led to successful leak closure.
A larger defect size was associated with a lower likelihood of closure (p = 0.067), suggesting a trend toward reduced efficacy in extensive leaks. Importantly, no EVT-related complications were observed throughout the study period.

Conclusion

EVT demonstrated a high success rate (87%) and an excellent safety profile for managing postoperative anastomotic leaks following upper GI surgery. Larger leak sizes showed a trend toward lower closure rates, highlighting the importance of early diagnosis and timely initiation of EVT when defects are smaller. Given its effectiveness and minimal risk, EVT should be considered a first-line endoscopic treatment for anastomotic leaks. Further studies are warranted to refine treatment protocols and establish standardized indications based on leak characteristics.

References

1. de Moura DTH, et al. Role of endoscopic vacuum therapy in the management of gastrointestinal transmural defects. World JGastrointestEndosc. 2019 May 16;
2. Mastoridis S, et al. Endoscopic vacuum therapy (EVT) in the management of oesophageal perforations and post-operative leaks. Minim Invasive TherAllied Technol. 2022 Mar;
3. Livingstone I, et al. Current Status of Endoscopic Vacuum Therapy in the Management of Esophageal Perforations and Post-Operative Leaks. Clin Endosc. 2021 Nov;
4. Panneerselvam K,et al. Endoscopic vacuum therapy for treatment of spontaneous and iatrogenic upper gastrointestinal defects. Clin Endosc. 2023 Nov.

Introduction

Capsule Endoscopy (CE) is a minimally invasive technique that allows for detailed visualization of the small bowel mucosa. Anemia and gastrointestinal (GI) bleeding are among the primary indications for CE. Accurate detection of vascular lesions is critical in this context; however, CE interpretation is time-consuming and subject to human error. Artificial intelligence (AI) has the potential to assist in this task, yet real-world studies assessing its clinical impact remain limited.

Aims & Methods

This study aimed to evaluate the performance of a deep learning convolutional neural network in detecting and identifying vascular lesions—specifically red spots and angiectasias—in complete CE videos.
We conducted a multicenter, prospective validation study comparing AI-assisted CE reading with standard, conventional interpretation. A total of 211 CE videos, acquired using three different devices across seven centers in Portugal, Spain, Brazil, and the United States, were included. Following initial standard readings, an independent expert performed AI-assisted readings using a deep learning model designed to detect and classify small bowel vascular lesions. Both reports were reviewed by a third-party expert from an independent center who adjudicated discrepant cases to establish the reference standard. Diagnostic performance was evaluated using standard metrics and the area under the receiver operating characteristic curve (AUC-ROC).

Results

AI-assisted reading identified 241 confirmed vascular lesions, compared to 158 detected through conventional reading. Sensitivity was significantly higher for AI-assisted reading (96.4% vs. 67.7%), though specificity was lower (75.7% vs. 93.5%). Overall accuracy was also higher with AI (89.7% vs. 76.1%). The AUC-ROC was 0.93 for AI-assisted and 0.78 for standard reading. Moreover, AI-assisted reading reduced the mean examination time to 316 seconds per video.

Conclusion

AI-assisted interpretation of full-length CE videos significantly outperforms conventional reading in the detection and classification of vascular lesions. The inclusion of videos from multiple CE systems addresses interoperability challenges, and the involvement of patients from four countries across two continents supports the model's generalizability and real-world clinical applicability.

Introduction

ERCP can still represents a challenge for endoscopists. In a variable percentage of cases (about 15%), cannulation of the common bile duct (CBD) is defined as “difficult”. In these cases, various advanced techniques are used to ensure access to the biliary tract. These methods can be summarised as follows: when an accidental cannulation of the pancreatic duct (PD) has occurred, the double guidewire technique (DGW) or the transpancreatic sphincterotomy (TPBS) technique can be performed; when access to the PD has not been achieved, freehand precut (trans papillary or fistulotomy) can be performed.¹
It has been shown that these methods are burdened by higher complication rates (in particular post- ERCP pancreatitis [PEP]) compared to standard cannulation of the CBD.² In particular, TPBS carries a stigma of risk and complexity. The ESGE guidelines propose its use as a second line after failure of DGW technique and only by expert endoscopists.¹ Recent studies have shown a certain distrust among endoscopists towards TPBS.³

Aims & Methods

We conducted a one-year prospective study with the aim of evaluating the efficacy and safety of TPBS in cases of difficult cannulation, comparing it with the DGW technique and trans papillary precut. All patients undergoing ERCP in a secondary centre were enrolled. A total of 169 ERCPs were performed by three endoscopists (two seniors and one junior with experience < 200 ERCPs). The most frequent indication was lithiasis of the CBD (74% of cases). The protocol adopted in case of difficult cannulation was the following: in the case of failed access to the PD, trans papillary precut was attempted. In the case of access to PD, the endoscopist chose at his discretion to perform the DGW technique or TPBS. In the case of PD cannulation, no pancreatic stent placement was performed. Other measures were taken to prevent PEP (rectal indomethacin and intravenous hydration during ERCP). Patients were followed up until discharge and peri- and post-procedural complications were recorded.

Results

The overall cannulation rate for naive papillae was 92.8%. Advanced techniques were used in 19% of the cases to achieve cannulation of the bile duct: 73% were successful. TPBS achieved 100% cannulation of CBP, compared to 66.7% of DWS and 55.6% of pre-cutting, showing a statistically significant better performance (p=0.02). A total of five bleedings, two cholangitis, one cholecystitis and two PEP were recorded. Of all these, only three (respectively one PEP, one bleeding and one cholecystitis) occurred after the above-mentioned advanced CBD cannulation methods were used.

Conclusion

In conclusion, this single-centre prospective observational study, despite its limited sample size, demonstrates that TPBS is a safe and effective method in case of difficult bile duct cannulation when PD cannulation is achieved. In particular TPBS seems to be more efficient than DGW and precut, showing a similar security profile. This technique can also be performed safely by non-expert endoscopists.
Finally, it is important to underline that, despite not placing the pancreatic prosthesis after cannulation of the PD (24 patients) none of them presented PEP.

References

1.Testoni PA, Mariani A, Aabakken L, Arvanitakis M, Bories E, Costamagna G, Devière J, Dinis-Ribeiro M, Dumonceau JM, Giovannini M, Gyokeres T, Hafner M, Halttunen J, Hassan C, Lopes L, Papanikolaou IS, Tham TC, Tringali A, van Hooft J, Williams EJ. Papillary cannulation and sphincterotomy techniques at ERCP: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2016 Jul;48(7):657-83. doi: 10.1055/s-0042-108641. Epub 2016 Jun 14. PMID: 27299638.
2.Fung BM, tea TCTabibian JH. Difficult Biliary Cannulation in Endoscopic Retrograd2 Cholangiopancreatography: Definitions, Risk Factors, and Implications. Eur Med J Hepatol. 2021 Aug;9(1):64-72. Epub 2021 Aug 5. PMID: 34621527; PMCID: PMC8494185.
3.Kouanda A, Bayudan A, Hussain A, Avila P, Kamal F, Hasan MK, Dai SC, Munroe C, Thiruvengadam N, Arain MA. Current state of biliary cannulation techniques during endoscopic retrograde cholangiopancreatography (ERCP): International survey study. Endosc Int Open. 2023 Jun 21;11(6):E588-E598. doi: 10.1055/a-2085-4565. PMID: 37564727; PMCID: PMC10410689.