Introduction

Aims & Methods

We conducted a retrospective analysis of 402 medical data from patients who were hospitalized with AP at our gastroenterology department of a university hospital from January 2018 to December 2023. The study included patients who underwent abdominal and pelvic computed tomography (CT) and our objective was to determine the prevalence of DVT in hospitalized AP patients and evaluate its influence on morbidity and mortality.

Results

Among 402 patients with acute pancreatitis (AP), 5.5% (n=22) developed DVT, with Portal vein thrombosis in 54.5%, Splenic vein thrombosis in 32%, and Superior mesenteric vein thrombosis in 13.6%. The mean age among patients with DVT was 58 ± 22 years compared to 56 ± 18 years (P=0.03). DVT incidence was significantly higher among patients with a Computed Tomography Severity Index score of ≥ 3 (63.6%, P=0.02). Among patients with pleural effusion, 13.7% without thrombosis and 31.8% with thrombosis were observed (P=0.02). An association was found between Systemic Inflammatory Response Syndrome (SIRS) and thrombosis, with 16.1% of patients with persistent SIRS not developing thrombosis compared to 40.9% with thrombosis (P=0.006). Similarly, among patients with a Bedside Index for Severity score > 2, 15.0% without thrombosis and 31.8% with thrombosis were observed (P=0.03). Among patients with WON, 6.9% without thrombosis and 35.0% with thrombosis were observed (P<0.001). The mean CRP level was significantly higher in patients with thrombosis (187 ± 100 vs 130 ± 107 mg/dl, P=0.02). Hypoalbuminemia was significantly more frequent in cases of thrombosis (P=0.002). During follow-up, among patients with pancreatic insufficiency, 0.9% without thrombosis and 10.0% with thrombosis were observed (P=0.001). However, no significant association was observed between thrombosis and mortality rate.

Conclusion

In summary, our study reveals the prevalence of DVT in AP patients, emphasizing its clinical significance. Factors such as higher severity scores and association with systemic inflammation underscore the importance of proactive management to mitigate DVT risk and enhance patient outcomes.

Introduction

Psychological therapies have been shown to be effective for treatment of patients with disorders of gut-brain interaction like irritable bowel syndrome (IBS). However, these therapies are time and personnel demanding which limits the access to this therapeutic option for many patients. Virtual reality (VR) creates an immersive environment where psychological interventions can be self-administered by the patient at home, thereby facilitating the access of these interventions to a large number of patients with minimal costs.

Aims & Methods

Our aim was to evaluate the effect of a psychological intervention delivered using VR on digestive symptoms in patients with IBS. Thirty-six patients with IBS (mean age 42±2 years, 89 % female) were randomized to receive a VR-based psychological intervention or placebo, using a randomized, single blind, parallel study design. The psychological intervention consisted in a 6-week program that started with a session of psychoeducation using a specifically created VR-video, followed by weekly sessions of group psychotherapy applied on-line by a psychologist. During the 6 treatment weeks, patients were asked to perform 15-30-min VR-sessions at home every day following a pre-designed protocol that incorporated progressive psychological interventions using VR-videos developed by a specialized company (XRHealth, Massachusetts, USA). The placebo group took a pill containing 0.3 g of glucose once daily. The primary outcome was the improvement of gastrointestinal symptoms (assessed by IBS-SSS) at the end of the intervention (6 weeks). Secondary outcomes included psychological comorbidities using the HADS (Hospital Anxiety and Depression Scale) and PSS (Perceived Stress Scale) questionnaires.

Results

Twenty-one patients were randomized to VR and fifteen patients to placebo. After 6 weeks of treatment, patients receiving the psychological intervention had a significantly greater reduction in IBS-SSS scores (score change -39±12) compared to patients on placebo (score change 1±19; p= 0.009). When analyzing the specific symptoms, abdominal pain had a significant reduction after psychological intervention (score reduction -8±3; p=0.015) and a tendency was identified for abdominal bloating (score reduction -6±5; p=0.097). Both symptoms remained unchanged after placebo (score change 1±6; p=0.719 and -0±6; p=0.695, pain and distension, respectively).
In addition, psychological intervention was followed by a greater improvement than placebo in HADS scores for anxiety (score change -2.35 ± 0.56; p=0.041 vs score change 0.00 ± 0.85 after placebo) and depression (score change -1.40± 0.71; p=0.005 vs score change 1.36 ± 0.50 after placebo). Stress evaluation using PSS also showed a greater reduction in stress perception in patients on psychological intervention (score change -5.15 ± 1.50) compared with patients on placebo 0.07 ± 1.35 (p=0.023).

Conclusion

A psychological intervention delivered at home using virtual reality is superior to placebo in relieving IBS symptoms, an effect that is associated to a reduction in anxiety, depression and stress in patients with IBS. These findings open the door to development of treatments in patients own home, and should facilitate the access to these treatments in large populations of patients. NTC06318572

Disclosure

No potential conflict of interest of any author

Introduction

Oesophageal ulceration (OU) is a frequent finding at oesophago-gastro-duodenoscopy (OGD). Despite limited data on the benefit of a repeat endoscopy, current guidelines recommend a follow-up OGD after six weeks to exclude underlying malignancy¹.

Aims & Methods

Aims: We aimed to explore the utility of a follow-up endoscopy after a diagnosis of oesophageal ulcer and identify predictors of oesophageal malignancy and dysplasia. Secondary aims were to estimate the environmental and financial impact of a follow-up endoscopy.
Methods: We collected demographic, endoscopy, and histology data from patients diagnosed with OU over a 5-year period (from 1^st January 2016 to 31^st December 2020 inclusive) at Leeds Teaching Hospitals NHS Trust. We collected data from the index OGD, follow-up OGD, and from their medical records up to 3 years after a diagnosis of OU at their index OGD. We examined the proportion of patients who were diagnosed with dysplasia or malignancy at follow-up or up to 3 years after their index OGD. Binary logistic regression was performed to identify predictors of oesophageal malignancy or dysplasia at index OGD, follow-up OGD, or 3 years after the index OGD. NHS national cost data for OGD, and carbon dioxide (CO2) emissions were estimated for all unnecessary follow-up OGDs^2,3.

Results

In total, 409 patients were diagnosed with OU. Of these, 33 patients were diagnosed with oesophageal cancer or dysplasia, with 30 diagnoses (90.9%) made at the index OGD and the remaining 3 (9.1%) at either the follow-up OGD or within 3 years of the index OGD. Of those 3 patients, one was diagnosed with oesophageal carcinoma, one with low grade dysplasia, and one with high grade dysplasia, all within a segment of Barrett’s oesophagus already diagnosed at the index OGD. Those who were diagnosed with oesophageal malignancy or dysplasia, compared to those who were not, were more likely to have larger ulcers (mean size (SD), mm, 15.9 (17.2) vs 9.50 (11.1), P = 0.003), endoscopic features suspicious for malignancy (69.7% vs 8.0%, P < 0.001), Barrett’s oesophagus (54.5% vs 14.4%, P < 0.001), and biopsies taken at index OGD (100% vs 64.1%, P < 0.001), and less likely to have a proton pump inhibitor prescribed (57.6% vs 86.4%, P < 0.001) after the index OGD. Following logistic regression controlling for all data, those with endoscopic features suspicious for malignancy (OR = 45.9; 95% CI 10.3 to 204) and those with Barrett’s oesophagus at index OGD (OR = 5.29; 95% CI 1.56 to 18.0) were more likely to be diagnosed with oesophageal cancer or dysplasia up to 3 years after the index OGD. A total of 376 unnecessary OGDs were undertaken over a 5-year period, the costs of which were estimated at £140, 248 and 10.6 tonnes of CO2 emissions.

Conclusion

Repeat OGD to exclude underlying malignancy following a diagnosis of oesophageal ulcer may only be required in those with endoscopic features suspicious for malignancy and those with Barrett’s oesophagus. Larger prospective multi-centre studies, with cost and carbon footprint analyses, are required to confirm our results and to inform guidelines.

References

1. Beg S. et al. (2017). Quality standards in upper gastrointestinal endoscopy: a position statement of the British Society of Gastroenterology (BSG) and Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland (AUGIS), Gut, 66(11):1886-1899. DOI: 10.1136/gutjnl-2017-314109
2. NHS (2023): National tariff payment system documents, annexes and supporting documents. Available at: https://www.england.nhs.uk/publication/national-tariff-payment-system-documents-annexes-and-supporting-documents/
3. Lacroute, J. et al. (2023), The carbon footprint of ambulatory gastrointestinal endoscopy, Endoscopy, 55(10): 918–926. DOI: 10.1055/a-2088-4062

Introduction

Globally, there is no standardized approach to sedation during endoscopic procedures, leading to variability in practices both regionally and across institutions. Sedation plays a crucial role in alleviating patient discomfort and ensuring the safety of endoscopic examinations and treatments. However, it occasionally leads to paradoxical reaction, which can adversely affect the outcomes of these procedures. As of 2023, in Japan, choice of sedatives and frequency of their use, and the incidence and management of paradoxical reaction during upper gastrointestinal endoscopy remain unclear.

Aims & Methods

This study is aimed to delineate the frequency and types of sedatives used in upper gastrointestinal endoscopy across different medical facilities in Japan and to investigate the extent of anesthesiologist involvement and the incidence and handling of paradoxical reactions. An anonymous online survey was distributed from November 28 to December 13, 2023, through mailing lists reaching about 2,500 gastroenterologists and endoscopists.

Results

The survey received responses from 635 participants including 418 hospital-based endoscopists, 118 clinic-based endoscopists, and screening 29 facility-based endoscopists. Sedation performed by anesthesiologists was found to be rare, with only 3.5% of examinations and 7.1% of treatments being managed by anesthesiologists once a week or more. 87% of respondents reported not using anesthesiologistsmanaged sedation at all for examinations, and 61% reported the same for treatments. Regarding the frequency of sedation use during examinations, 9.8% of respondents reported using sedation in over 95% of cases, and 53% reported using it in more than half of the cases. 6.6%, reported not using sedation at all. In treatments, 86% of respondents used sedation in over 95% of cases, and 96% used it in more than half of their cases.

Midazolam was the most common sedative for examinations (n=593), chosen in over 80% of cases by 54% of respondents, while only 9.9% never selected it. Meperidine was frequently used by 10% of respondents in similar proportions. Other sedatives like flunitrazepam, diazepam, and propofol were selected by 5.0%, 3.5%, and 2.5% of respondents, respectively.

For treatments (n=401), midazolam was again the most frequently chosen, selected in over 80% of cases by 72% of respondents. Other commonly used sedatives were meperidine and pentazocine, selected in over 80% of cases by 29% of respondents, with propofol and dexmedetomidine each chosen by 12%.

64% of endoscopists who use sedative drugs experienced difficult cases to continue procedures due to paradoxical reactions, with a median incidence of 5% of cases and median of two cases are required to discontinue procedures. Midazolam was the most common cause, reported by 91% of respondents, followed by flunitrazepam (13%), diazepam (8.8%), and propofol (8.3%). The typical response involved physically restraining the patient with multiple staff members' assistance. Eighteen percent of respondents did not use antagonist drugs for examinations, and 22% for treatments.

Conclusion

In Japan, over half of upper gastrointestinal procedures used sedation, with 53% in diagnostics and 96% in treatments predominantly using midazolam. Additionally, 64% of physicians experience difficulties with paradoxical reactions during procedures under sedation by themselves.. These reactions are recognized as significant challenges that must be addressed in the management of sedation for upper gastrointestinal endoscopy.

Introduction

Eosinophilic esophagitis (EoE) is treated with oral antacids, steroid-swallowing therapy, and antigen elimination diet. Despite treatment, EoE often recurs, and the mechanism has not been elucidated. Recently, pathogenic helper Th2 (Tpath2) cell was reported to be responsible for chronic eosinophilic inflammation, for example asthma and eosinophilic chronic rhinosinusitis, by producing large amount of Th2 cytokine [1]. Our previous research has identified the presence of Tpath2 cells in the esophageal mucosa of patients with EoE [2]. However, there has been no previous report whether Tpath2 remains in the tissues during remission or after treatment.

Aims & Methods

The aim of this study was to examine the association between the progression of EoE and Tpath2 cells in the esophageal mucosa. We collected esophageal mucosa biopsies regardless of the endoscopic findings from 11 patients (generally 2 specimens from 5cm and 15cm oral side of esophagogastric junction respectively) previously diagnosed as EoE. Flow cytometry was utilized to quantify the frequency of eosinophils and Tpath2 cells in these samples. Each patient’s medical history or disease course were also reviewed.

Results

Of the 11 patients, 6 (54.5%) were in remission from EoE and 5 (45.5%) had active disease. Notably, abnormal frequency of Tpath2 cells within the esophageal mucosa of the patients in remission (median 1.41%, range 0.31 - 2.85%) were observed to the same levels in those with active disease (median 2.48%, range 1.02 - 4.18%) (P=0.33. Mann-Whitney test.). In remission cases, the median period from confirmation of remission to this biopsy was 38 months (range 24 - 49) , meaning T path2 cells still remained at least for that period after remission. Among patients in remission at the time of biopsy, two patients who were absence of treatment relapsed EoE during subsequent disease course.

Conclusion

Tpath2 cells remain within the esophageal mucosa of patients with EoE for a relatively long time regardless of eosinophil control. Although further investigation is needed, some cases of EoE recurred during remission phase, suggesting that Tpath2 cells may also be involved in the recurrence.

References

1. Nakayama T et al. Th2 cells in health and disease. Annu Rev Immunol. 2017; 35:53-84.
2. Kaneko T et al. Amphiregulin-producing T helper 2 cells facilitate esophageal fibrosis of eosinophilic esophagitis. J Allergy Clin Immunol Global. 2024; Epub ahead of print

Introduction

High-risk human papillomavirus (hr-HPV) has been associated with a subset of Barrett’s dysplasia (BD) and oesophageal adenocarcinoma (OAC).^1,2,3,4 The L1 major capsid protein has been closely linked to disease regression and is a prognostic factor in HPV driven cancers of the cervix and anus.​^5,6​​​​ The progression of cervical intraepithelial neoplasia to invasive cancer is accompanied by a loss of viral L1 capsid protein expression.

Aims & Methods

Thus, in a retrospective, cross-sectional study, we investigated L1 protein expression in HPV-positive patients representing the oesophageal squamous (controls) [Group1]-Barrett’s metaplasia [Group 2]-low-grade dysplasia [Group 3]-high-grade dysplasia [Group 4]-adenocarcinoma [Group 5] sequence. L1 protein immuno-histochemical staining was correlated with p16 overexpression and E6/E7 mRNA in-situ hybridization. The association between the 5 patient groupings and L1 expression was analysed using the Chi-square test. Multivariable logistic regression was undertaken to investigate the above association with adjustment of potential confounders (age, gender, BMI, ever smoked and excess alcohol). Adjusted odds ratio (95% CI) was calculated.​​​​​

Results

^​​​​​​Of 116 HPV DNA-positive patients [(age range: 19-90, mean (SD), 63.2 (13.5)], 88 males and 28 females), 73 (62.9%) were genotype 16, 37 (31.9%) genotype 18 and 6 (5.2%) were genotype 6. L1 nuclear staining was observed in 64 individuals. L1 expression was detected in 84.9% (28/33) of controls; 94.1% (16/17) of BO patients; 50% (7/14) of LGD subjects; 38.1% (8/21) of HGD individuals and 16.1% (5/31) of OAC patients; [adjusted P < 0.0001]. Conversely, p16 was present in 9.1% (3/33) of controls, 17.7% of BO (3/17), 57.1% (8/14) in LGD individuals, 61.9% (13/21) of HGD patients and 64.5% (20/31) of OAC subjects [p<0.0001]. Corresponding figures for E6/E7 mRNA positivity was 6.1% (2/33), 23.5% (4/17), 28.6% (4/14), 38.1% (8/21) and 45.2% (14/31) respectively [p=0.008]. Expression of HPV-L1 and p16 or L1 and E6/E7 mRNA was largely mutually exclusive.

Conclusion

HPV L1 capsid expression is incrementally lost with increasing oesophageal disease severity as in viral driven anal and cervical lesions. Utility of L1 alone or in combination with p16/E6/E7 mRNA in stratifying HPV-positive oesophageal lesions for treatment should be further explored.

References

1. Rajendra S, Wang B, Snow ET, et al. Transcriptionally active human papillomavirus is strongly associated with Barrett’s dysplasia and esophageal adenocarcinoma. Am J Gastroenterol 2013;108:1082–1093.
2. Rajendra S, Yang T, Xuan W, et al. Active human papillomavirus involvement in Barrett's dysplasia and oesophageal adenocarcinoma is characterized by wild-type p53 and aberrations of the retinoblastoma protein pathway. Int J Cancer. 2017;141(10):2037-2049.
3. Li X, Gao C, Yang Y, et al. Systematic review with meta-analysis: the association between human papillomavirus infection and oesophageal cancer. Aliment Pharmacol Ther. 2014;39(3):270-281.
4. Rajendra, S., W. Xuan, N. Merrett, et al. Survival Rates for Patients With Barrett High-grade Dysplasia and Esophageal Adenocarcinoma With or Without Human Papillomavirus Infection. JAMA Netw Open. 2018; 1: e181054.
5. Choi YS, Kang WD, Kim SM, et al. Human papillomavirus L1 capsid protein and human papillomavirus type 16 as prognostic markers in cervical intraepithelial neoplasia 1. Int J Gynecol Cancer 2010;20(2):288-293.
6. Hernandez J, Elahi A, Siegel E, Coppola D, Riggs B, Shibata D. HPV L1 capsid protein detection and progression of anal squamous neoplasia Am J Clin Pathol 2011; 135: 436-41.

Disclosure

None