Introduction

Allogenic hematopoietic stem cell transplantation is one of the effective treatment options for hematological diseases such as acute myeloid leukemia or malignant lymphoma. Graft versus host disease (GHVD) in the gastrointestinal tract and/or cytomegalovirus (CMV) colitis is often seen after stem cell transplantation. We as endoscopists perform small intestine capsule endoscopy (CE) examinations for patients who are suspected of GVHD in the gastrointestinal tract and CMV colitis.
Gastric retention of CE makes it difficult to observe complete small bowel in several frequencies. It is well known that GVHD in the gastrointestinal tract decreases the motility of the stomach, and is one of the causes of gastric retention. We are now aware of the increasing ratio of gastric retention of the CE examination after late 2018 in our institution. This is also the period that Letermovir was introduced into our hospital. Therefore, we hypothesize that Letermovir may affect the gastric retention of CE examination and investigated the relationship between Letermovir administration and gastric retention of CE examination.

Aims & Methods

A total of three hundred and thirty-five CE examination among 439 CE performed for patients with allogeneic stem cell transplantation between July 2005 and July 2022 in our hospital was analyzed. One hundred and four CE examinations without CE video data or transported using endoscopic assistance were excluded. Data was acquired from reporting system of CE. Gastric retention was defined that gastric transit time (GTT) being longer than 390 minutes because the average battery duration was 13 hours. CE examination during Letermovir administration was defined as Letermovir being administrated irrespective of administration oral or intravenously. the day CE examination was performed The ratio of gastric retention was compared between the Letermovir administrated and Control groups.

Results

Among 335 CE examination, 183 was male and 152 was female. The median age of the patients was 55 years old (range 15 – 86). Median GGT was 96 minutes (range 31 – 807 minutes). Gastric retention with GTT longer than 390 minutes was observed in 30 CE examinations (9.0%). CE examination during the administration of Letermovir was 142 (42.4%). Gastric retention of CE examination in the Letermovir administrated group was significantly higher than the Control group (19 (13.4%) vs 11 (5.7%), p = 0.0150).

Conclusion

Letermovir might potentially cause gastric retention of CE examination for patients with allogeneic stem cell transplantation. Endoscopic assistance, the transport of the retained CE into the duodenum using snare or net devices based on the real-time monitoring function of CE, may be one of the options to improve efficient CE examination for patients with Letermovir administration.

Introduction

Acute upper gastrointestinal bleeding and timing to endoscopy are a recognised as risk factors for mortality. European Guidelines * suggest that the hemodynamical resuscitation could be performed before the endoscopy, however, indications are lacking about the timing of blood transfusions.

Aims & Methods

The aim of the study is to evaluate the transfusion timing to reduce death risk in patients with upper gastrointestinal bleeding. This is a prospective multicentre cohort study, including all consecutive hospitalized patients with upper gastrointestinal bleeding (UGIB). Clinical, endoscopic source of bleeding, medical and endoscopic treatment, time to endoscopy, and timing to transfusion were collected. We adopted the ESGE* guidelines to define the need for transfusion, timing to endoscopy and mortality. We considered timing to transfusion before or after the endoscopic procedure. Statistics: multivariate backward logistic regression was used to estimate the adjusted odds ratio death risk for variables with main clinical relevance or highly statistical significance at univariate analyses. Variables identified by the logistic regression were used into the propensity-score matching to compare the death risk between the two groups.

Results

2,017 out of 3324 patients received a transfusion and were included in the analysis; the mean age was 69.7 [±15.1], male was 1,365 (67.7%); the source of bleeding was non-variceal in 1634 patients (81 %), 178 patients died (8.8%); 69 out of 700 (9.9 %) died in the group transfusion before endoscopy; 109 out 1317 (8.3 %) in the group transfusion after endoscopy with an OR 1.2 (C.I. 95% .86 to 1.68) p<= 0.23. Mortality between the two groups did not significantly differ when haemoglobin levels at admission were considered, nor after adjustment for potential confounding variables, including ASA score, in-hospital bleeding, haematemesis at presentation, shock at admission, altered mental status and timing to endoscopy. Propensity score matching analysis indicated that among patients who received a transfusion, the risk of death decreased when the transfusion was administered before the endoscopy and the haemoglobin level was below 7 g/dL (coefficient = -0.06, p = 0.06; see Table).

Conclusion

Red pack cell transfusions before or after endoscopy did not modify the death risk in patients with acute upper gastrointestinal bleeding; the death risk was less frequent in patients transfused before endoscopy and with a haemoglobin value lower than 7 gr/l. However, this risk increased in those patients transfused before endoscopy and with a haemoglobin value > 8 gr/l.

References

* Ian M. Gralnek et al. Endoscopy 2021; 53: 300–332

Introduction

Graft-versus-host disease (GVHD) in the lower gastrointestinal tract and cytomegalovirus (CMV) colitis frequently occur as adverse events after allogeneic bone marrow transplantation. GVHD in the lower gastrointestinal tract is treated with prednisolone (PSL), while it aggravates CMV colitis. Therefore, a differential diagnosis between GVHD in the lower gastrointestinal tract and CMV colitis is essential to determine the treatment strategy.
CMV colitis is histologically diagnosed by biopsy during colonoscopy (CS), however, it takes 1-2 weeks to confirm the diagnosis. Therefore, it is key to diagnose based on endoscopic findings starting treatment promptly for patients with suspected CMV colitis after allogeneic bone marrow transplantation. It is also mandatory to accurately diagnose CMV colitis at an early stage because CMV colitis is known to be challenging to control and has a poor prognosis when complicated with GVHD in the lower gastrointestinal tract.
We have previously reported that ulceration and erosion are independent factors that can predict CMV colitis in colonoscopy. We hypothesized that CMV colitis could be predicted by findings of ulceration and/or erosion in small intestine capsule endoscopy (CE).

Aims & Methods

In this study, we investigated whether the findings of ulceration and/or erosion in capsule endoscopy have an additive effect on colonoscopy in the diagnosis of CMV colitis.
A total of seventy-five patients who underwent both CS and CE from 2007 to 2020 were included among 271 patients with suspected lower gastrointestinal GVHD based on their clinical course. All colonoscopy images were reviewed by one expert. Capsule endoscopic findings were obtained from reporting system. Each examination was evaluated for the presence of ulcerations and erosions. CMV colitis was defined as histopathologic evidence of at least one CMV infected cell in the biopsy specimens of the colon mucosa. “Colonoscopy diagnosed CMV” was defined when the ulceration or erosion was observed by CS. “CE diagnosed CMV” was defined when the ulceration or erosion was observed by CE or CS, that showed an additional effect of CE examination on CS examination for diagnosis performance of CMV.
The diagnostic performance of “Colonoscopy diagnosed CMV” and “CE diagnosed CMV” were investigated.

Results

The median age of the patients was 55 years (range 16-69), and the male was 50 and the female was 25. Thirty-six patients had GVHD alone, 4 patients had CMV alone, and 26 patients had both GVHD and CMV. Therefore, 30 patients were pathologically CMV-positive.
Of the 30 patients with CMV colitis, 14 showed ulceration or erosion on CS. The sensitivity and specificity of “Colonoscopy diagnosed CMV” were 46.7% and 71.1%, respectively.
Of 30 patients with CMV colitis, 19 patients had ulceration or erosion in “CE diagnosed CMV“. The sensitivity and specificity of CMV enteritis with “CE diagnosed CMV” were 63.3% and 48.9%, respectively.

Conclusion

When CE was performed in patients with suspected post-transplant GVHD or CMV enteritis and positive findings of ulceration or erosion were used to diagnose CMV colitis, the sensitivity to diagnose CMV colitis with CE additional to CS was 16.6% higher than that with CS alone. The results suggest that CE may be useful in decreasing the overlooked CMV colitis.

Introduction

Gastroparesis is common in patients with Diabetes mellitus, especially in those with poor glycemic control. Due to this association, diabetic patients are at risk of prolonged gastric transit time (PGTT) when undergoing small-bowel capsule endoscopy (SBCE).

Aims & Methods

In this investigation we aimed to assess if there was an association between hemoglobin A1c levels and PGTT in diabetic patients undergoing SBCE.
We have conducted a single-center retrospective study including all consecutive diabetic patients undergoing SBCE for two years. Patients without a valid hemoglobin A1c measurement within 3 months from SBCE were excluded. The assessed outcome was PGTT (defined as SBCE remaining in the stomach for >1h, requiring prokinetic administration and/or endoscopically assisted capsule delivery into the duodenum). Possible confounders – age, gender, inpatient status, smoking habits, diagnosis of IBD, thyroid disease, prokinetics or antidepressants regular usage - were also assessed.

Results

Final sample included 77 patients, 40 (51.9%) of them males, with a mean age of 70±10 years. PGTT occurred in 33 (42.9%) individuals. Mean hemoglobin A1c levels were significantly higher in diabetic patients with PGTT (7.4±0.8% vs 6.5±0.8%; p<0.001). In a multivariate analysis including significant confounders, hemoglobin A1c levels were still an independent predictor of PGTT (B=1.35; p<0.001). Single-handedly, hemoglobin A1c levels demonstrated very good acuity in predicting PGTT (AUC=0.80; p<0.001), with an optimal cut-off of HbA1c ≥6.8% (sensitivity 81% and specificity 73%).

Conclusion

Hemoglobin A1c levels significantly influenced the occurrence of PGTT in diabetic patients undergoing SBCE. This may eventually allow the performance of preemptive measurements to avoid PGTT in diabetic patients with poor glycemic control.

Introduction

Obscure gastrointestinal bleeding (OGIB) is defined as gastrointestinal bleeding of unknown origin that persists or recurs despite a negative finding from an initial bidirectional endoscopy. According to recent guidelines, capsule endoscopy was recommended first in overt OGIB, but it is unclear when it is appropriate to perform capsule endoscopy in overt OGIB patients.

Aims & Methods

We aimed to analyze clinical outcomes with regard to the timing of capsule endoscopy in overt OGIB patients. We conducted a single-center retrospective study enrolling patients who had undergone capsule endoscopy for overt OGIB between February 2010 to December 2021. We included hospitalized patients who underwent capsule endoscopy for overt OGIB after negative bidirectional endoscopy. We investigated the diagnostic yield of capsule endoscopy, rebleeding rate, length of hospital stay, initial hemoglobin, and the amount of blood transfusion with regard to the timing of capsule endoscopy.

Results

A total of 118 patients underwent capsule endoscopy to assess overt OGIB. The diagnostic yields in the groups that underwent capsule endoscopy < 48h and > 48h from the last overt OGIB were 50.0% and 22.0%, respectively (P=0.017). Rebleeding rate and the length of hospital stay were not significantly different between the two groups. Initial hemoglobin level in the group who underwent capsule endoscopy > 48h group was lower than in the < 48h group (8.8±3.0 vs. 10.7±3.7, P=0.015).

Conclusion

Performing capsule endoscopy within 48 hours from the last overt OGIB resulted in a higher diagnostic yield. Performing capsule endoscopy within 48 hours may improve the clinical outcomes of patients with overt OGIB.

Introduction

Endoscopic submucosal dissection (ESD) is a widely used treatment for early gastric tumors, but delayed bleeding remains a significant complication, especially in patients receiving antithrombotic therapy. As the population ages, the need for effective preventive strategies is growing.
Although various methods such as PGA sheets and fibrin glue have been explored, no definitive approach has been established. Moreover, a reliable animal model to evaluate strategies for preventing delayed bleeding does not currently exist.
To address this issue, Taguchi et al. developed a novel endoscopically sprayable wound dressing composed of hydrophobized gelatin microparticles (hMPs), which exhibit strong tissue adhesion. In preclinical studies using miniature swine, hMPs have shown various therapeutic effects on post-ESD ulcers, including anti-inflammatory and anti-fibrotic effects, as well as promotion of perforation closure.

Aims & Methods

This study aimed (1) to establish an animal model of delayed bleeding after gastric mucosal injury, and (2) to evaluate the preventive effect of hMPs using this model.
(1) A delayed bleeding model was created by producing mucosal defects in the stomach using endoscopic mucosal resection with ligation (EMR-L), followed by continuous heparin infusion to maintain an activated clotting time (ACT) ≥220 seconds, which consistently induced delayed bleeding.
(2) Using this model in three miniature swine, we evaluated the preventive effect of hMPs by endoscopically spraying hMPs onto a total of 36 ulcers (12 per animal). We assessed delayed bleeding, as well as the retention and coverage of hMPs at the ulcer base.

Results

(1) In the heparin-treated group, delayed bleeding was observed in 3 of 4 animals (75%). All three animals whose maximum ACT before the start of continuous heparin infusion exceeded 220 seconds developed delayed bleeding. In contrast, no ACT prolongation or delayed bleeding was observed in the non-heparin-treated group (n = 3) at 24 hours.
(2) In the hMPs spray group (n = 3), all animals had ACT ≥220 seconds, and hMPs were sprayed onto 12 mucosal defects per animal (total 36 lesions). No delayed bleeding occurred in any animal. hMPs were retained at all ulcer sites, yielding a 100% retention rate. The ulcer base coverage by hMPs was as follows: 100% in 55.6% of sites (20/36), 75–99% in 19.4% (7/36), and 50–74% in 25.0% (9/36). No sites had coverage below 50%.
Exposed vessel-like structures were identified in 36.1% of the ulcers (13/36), and hMPs were found to adhere to all of these sites.

Conclusion

An animal model of delayed bleeding after endoscopic resection of the gastric mucosa was successfully established by maintaining an ACT ≥220 seconds through continuous heparin infusion. In this model, hMPs remained well on the ulcer base and provided broad coverage of mucosal defects. These findings suggest that hMPs may be effective in preventing post-endoscopic bleeding, particularly in patients receiving antithrombotic therapy.

Introduction

Capsule endoscopy (CE) is an important non-invasive diagnostic modality for the evaluation of small bowel and colon. However, in patients with gastrointestinal tract anatomy altered by surgical interventions, there can be a higher risk of incomplete examination of small bowel and colon.

Aims & Methods

The aim of our study was to evaluate the rate of complete examination and diagnostic yield of CE, in patients with previous gastrointestinal surgery, as well as the impact of endoscopic placement of CE using the AdvanCE device.
Retrospective, cohort study, including patients submitted to CE of the small bowel or colon, detailing patients with previous gastrointestinal surgeries and with endoscopic placement of CE.

Results

A total of 642 patients was included, 17 with previous gastrointestinal surgery (2.6%), from which 9 with gastric bypass and Y-de-Roux (with 3 having esophagojejunostomy and 6 gastrojejunostomy), 3 patients with Bilroth II, 2 with Bilroth I e 3 patients with sleeve gastrectomy.
Endoscopic placement of CE was performed at the discretion of the responsible gastroenterologist and occurred in 8 patients (1.2%). It was 13.3 times more likely to be performed in patients with previous gastrointestinal surgery (11.8% vs 1.0%, p=0.017).
In patients without endoscopic placement of CE, the rate of complete examination of the gastrointestinal tract, adequate bowel preparation and diagnostic yield was comparable between those with and without previous gastrointestinal surgery: 86.7% vs 85.3% (p=1.000), 73.3% vs 78.1% (p=0.751) e 40% vs 38% (p=0.875), respectively.
In patients with gastrointestinal surgery, the rate of complete examination of the gastrointestinal tract was comparable between patients with and without endoscopic placement of CE: 50.0% vs 86.7% (p=0.331). The rate of complete examination of the gastrointestinal tract, adequate bowel preparation and diagnostic yield was not influenced by the different types of surgery, considering patients with gastric bypass vs Y-de-Roux vs Bilroth II: 75.0% vs 80.0% vs 66.7% (p=0.915), 50.0% vs 60.0% vs 66.7% (p=0.902) e 25.0% vs 20.0% vs 66.7% (p=0.363), respectively.

Conclusion

CE is effective, even in patients with previous gastrointestinal surgery, with diagnostic yield and rate of complete examination of the gastrointestinal tract similar to other patients, regardless of the type of surgery. Endoscopic placement of CE with AdvanCE device does not seem to improve outcomes in patients with previous gastrointestinal surgery.