Introduction

Colorectal cancer (CRC) screening is well established worldwide. However, the suboptimal sensitivity of the Fecal Immunochemical Test (FIT) for precancerous lesions justifies the search for new tools, namely microRNAs (miRs). In recent years, the detection of these molecules in liquid biopsies has gained increasing interest, as they reflect CRC progression and enable the early detection of precancerous lesions. Moreover, using miRs as a blood-based screening test could potentially increase patient adherence.

Aims & Methods

In this context, we aimed to identify circulating miR profiles for the early detection of CRC. Based on our previous literature review, we selected four miRs (miR-21-5p, miR-92a-3p, miR-451a and miR-199a-5p) with the best performance for the detection of CRC and high-grade dysplasia lesions (HGD). MiR expression was evaluated using RT-qPCR in plasma samples from 80 individuals who underwent colonoscopy with different clinical outcomes, namely, individuals without lesions found on colonoscopy, low-grade dysplasia lesions, high-grade dysplasia lesions, and patients diagnosed with CRC.

Results

Our findings demonstrate a decreased expression of all miRs in CRC and HGD lesions. Regarding HGD identification, miR-21-5p demonstrate a sensitivity of 68% (95% CI: 46 – 85%) and a specificity of 100% (95% CI: 84 – 100). Moreover, miR-92a-3p, miR-451a and miR-199a-5p demonstrated a sensitivity higher than 85% for HGD lesions detection, despite low sensitivity (around 70%). Concerning CRC detection, miR-92a-3p and miR-199a-5p demonstrated sensitivity of approximately 65%, with specificities of 70%, for miR-92a-3p (95% CI: 48 – 85%), and 80% for miR-199a-5p (95% CI: 58 – 92%). Furthermore, miR-21-5p showed outstanding performance in CRC identification with a sensitivity of 95% (95% CI: 75 – 100%), for an AUC of 0.900 (95% CI: 0.807 – 0.993). Moreover, when a negative result was obtained for one of these miRs, the presence of colorectal cancer lesions could be accurately excluded (negative predictive value: 98%).

Conclusion

These findings suggest that circulating miRs have the potential to improve the detection of precancerous lesions, surpassing the performance of FIT. Moreover, given their accuracy in identifying individuals without lesions, they could serve as effective confirmatory screening tools, reducing the number of unnecessary colonoscopies.
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Introduction

Behaviours such as supra-gastric belching, gastric belching, and aerophagia, often identified during oesophageal physiology studies (e.g., 24-hour pH and impedance study), are known to exacerbate symptoms like reflux, bloating, and regurgitation. These behaviours are frequently misunderstood and may lead to unnecessary referrals to specialists or invasive interventions. Upper GI biofeedback (UGI BFB) therapy offers a tailored, non-invasive approach to help patients manage these behaviours. By teaching specific techniques such as diaphragmatic breathing, open-mouth posture, and the multiple rapid swallow technique, patients are empowered to take control of their symptoms, improve their quality of life, and reduce reliance on surgical or gastroenterology pathways.

Aims & Methods

• Participants: Between December 2022 and December 2024, 35 patients were referred for UGI BFB therapy. Most referrals (n=31) came after oesophageal physiology studies, with additional referrals from gastroenterologists for belching and bloating (n=2) and from clinical endoscopists for persistent hiccups and audible wheezing (n=2).
• Intervention: Patients attended a one-hour education session in the Gastrointestinal (GI) Physiology unit. This included a review of diagnostic findings and practical training in diaphragmatic breathing, open-mouth posture, and the multiple rapid swallow technique. A follow-up telephone consultation at 6–8 weeks allowed for monitoring progress. For cases of poor oesophageal clearance, referring clinicians were advised to consider prokinetics. For frequent gastric belching, small intestinal bacterial overgrowth (SIBO) breath testing was recommended to assess any additional contributing factors.

Results

• Supra-gastric belching episodes were reduced by 50% (mean: 24 episodes pre-therapy to 12 post-therapy; p<0.001).
• GERD-HRQL scores improved by 45%, indicating significant quality-of-life improvements (mean: 22 pre-therapy to 12 post-therapy; p<0.001).
• 75% of patients reported substantial reductions in belching, bloating, and reflux-like symptoms.
• Half of the patients (50%) no longer required specialist referrals, as symptoms were successfully managed with therapy or GP-led interventions, including prokinetics or medications for hypersensitivity.
• Stress emerged as a critical factor for most patients. Relaxation techniques, mindfulness, and stress management strategies played an important role in symptom control. One patient, who became a mental health first aider at work, reported long-term symptom relief due to stress reduction efforts.

Conclusion

Upper GI biofeedback therapy is a valuable approach for addressing behavioural contributors to symptoms like air swallowing, belching, and bloating. A multidisciplinary approach, involving cognitive behavioural therapy or hypnotherapy alongside UGI BFB, can be highly beneficial. The GI Physiology team also recognises its limitations and has found that referrals to Speech and Language Therapy can be instrumental when patients are unable to engage fully with the therapy. This collaborative, patient-centred approach ensures that UGI BFB therapy not only reduces the need for invasive procedures and specialist consultations but also empowers patients to adopt long-lasting lifestyle and behavioural changes.

Introduction

EUS-guided choledochoduodenostomy using a lumen-apposing metal stent (EUS-CDSL) has been shown in randomized controlled trials (RCT) to be effective compared to endoscopic retrograde cholangiopancreatography (ERCP) in patients with advanced malignant distal biliary obstruction (MDBO). We aimed to further ascertain the safety of EUS-CDSL, which has been limited by inadequate trial sample sizes.

Aims & Methods

We undertook aggregate and individual patient data (IPD) meta-analyses following the PRISMA-IPD statement. A literature search was performed from January 2013 to November 2024 using OVID MEDLINE, EMBASE, Cochrane Library, and ISI Web of Science. Additional searches were performed for abstracts and the grey literature. RCTs comparing EUS-CDSL to ERCP were included. The primary outcome was the rate of procedure-related 14-day severe or fatal adverse events (AE). Secondary outcomes included technical success, 30-day AE, clinical success, stent dysfunction, and procedure time.

Results

A total of 2679 citations were screened with three RCTs included (519 patients). There was no difference in severe or fatal AEs between EUS-CDSL and ERCP (OR 0.64, 95% CI 0.22- 1.83 for IPD data and RR 0.76, 95% CI 0.22, 1.77 for aggregate data). Technical success was greater for EUS-CDSL (OR 4.22, 95% CI 2.35,7.61 and RR 1.14, 95% CI 1.04, 1.25) with shorter procedural time (mean difference -10.50 minutes (95% CI -15.28, -5.73). No significant differences were noted in 30-day AEs, clinical success, and stent dysfunction.

Conclusion

Our aggregate and IPD meta-analyses demonstrate the safety of EUS-CDSL as a first-line alternative to ERCP in advanced MDBO. In addition, EUS-CDSL is technically superior in terms of success rate and procedure time.

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) is now the gold standard for treating biliopancreatic conditions. With growing operator experience and significant advancements in endoscope and instrument design, outcomes have markedly improved. However, the procedure still carries a risk of complications and is not always successful in clearing bile duct stones on the first attempt. In this context, our study aims to evaluate the complication rate of ERCP in the management of common bile duct stones and to explore what factors predict failure to clear these stones during the initial procedure.

Aims & Methods

The aim of this study is to evaluate the predictive factors associated with failure of complete biliary stone clearance during the initial endoscopic retrograde cholangiopancreatography (ERCP) procedure. This is a retrospective, descriptive, and analytical study conducted over a 20-year period, from September 2005 to September 2025. It includes all patients with bile duct stones who underwent ERCP with endoscopic sphincterotomy, followed by stone extraction using standard techniques such as an extraction balloon or Dormia basket.

Results

A total of 1,080 ERCP procedures were performed for the extraction of bile duct stones. The mean age of the patients was 58.9 ± 14.4 years, with a female predominance (59.5%). The average diameter of the common bile duct (CBD) was 13.4 ± 4.31 mm, and biliary strictures were observed in 6.3% of cases. The primary duct clearance rate was 75.1%, while supplementary techniques were required in 22.7% of cases.
On univariate analysis, several factors were significantly associated with failure of stone clearance using standard techniques: younger age (OR: 0.9; 95% CI: -0.03 to -0.01; p < 0.001), male gender (OR: 0.7; 95% CI: -0.5 to -0.02; p = 0.036), history of cholecystectomy (OR: 1.3; 95% CI: 0.02 to 0.6; p = 0.035), presence of cholangitis (OR: 0.4; 95% CI: -1.1 to -0.4; p < 0.001), CBD dilation >15 mm (OR: 0.8; 95% CI: -0.2 to 0.1; p < 0.001), biliary stricture (OR: 0.3; 95% CI: -1.7 to -0.7; p < 0.001), and presence of impacted and/or large stones (OR: 0.1; 95% CI: -2 to -1; p < 0.001).
Multivariate analysis identified four independent predictors of primary clearance failure: presence of cholangitis (OR: 1.9; 95% CI: 0.2 to 1; p = 0.001), impacted and/or large stones (OR: 2.5; 95% CI: 0.5 to 1.3; p < 0.001), CBD dilation >15 mm (OR: 0.88; 95% CI: -0.17 to -0.07; p < 0.001), and biliary stricture (OR: 2.9; 95% CI: 0.4 to 1.7; p = 0.002).
Following the application of supplementary techniques, the overall bile duct clearance rate increased to 92.4%.

Conclusion

In our study, the main predictors of failure to achieve primary common bile duct clearance were cholangitis, the presence of impacted and/or large stones, CBD dilation greater than 15 mm, and biliary strictures.

Introduction

A biliary stricture is a narrowing of intrahepatic and/or extrahepatic biliary system with upstream dilatation¹; 70-80% of biliary strictures are malignant¹ therefore histological diagnosis is necessary to distinguish benign from malignant causes and guide management. Strictures without confirmed histology are referred to unexplained biliary strictures². ESGE (European Society of Gastrointestinal Endoscopy) guidelines recommend an integrated diagnostic approach that combines multiple techniques to improve diagnostic accuracy. Endoscopic ultrasound(EUS) has demonstrated high sensitivity for evaluating biliary strictures and unexplained common bile duct (CBD) dilatation, due to its ability to provide high-resolution images of CBD walls and surrounding structures, so is the preferred diagnostic modality for both imaging and tissue acquisition(TA), even in absence of abnormal laboratory test.¹ The introduction of ancillary techniques, as DFI (Detective Flow Imaging), which enables the detection of low-velocity blood flow without the use of contrast media, represents a potential useful addition in the diagnostic algorythm³.

Aims & Methods

The aim of this single-centre retrospective study is to validate the role of EUS-DFI in characterizing unexplained biliary strictures and CBD dilatation. We included consecutive patients (pts) with unexplained biliary strictures/CBD dilatation who underwent biliopancreatic EUS between January 2024 and April 2025 at the Digestive Diseases Unit of Sant’Andrea University Hospital, Rome. During EUS, biliary stricture (lesions or thickening of CBD wall) were described as hypoechoic or isoechoic. DFI was performed to evaluate strictures: if microvascularization was observed, vascular pattern was classified as regular or irregular⁴. Results were compared with the final diagnosis, defined by histopathology and/or ≥6 months clinical follow-up as gold standard. TA was performed with EUS-FNB (fine needle biopsy) and/or ERCP(Endoscopic Retrograde Cholangiopancreatography) intraductal biopsies/brushing.

Results

Of 13 patients included, 8(61.5%) were male, median age 72 (range 56-86). All underwent Magnetic Resonance Imaging/Contrast-Enhanced Computed Tomography as first line imaging: 3(23%) had a perihilar stricture, 9(69%) a medio-distal, 1(8%) had “in toto” CBD thickening. Among the 13 strictures, EUS identified 10(76.9%) lesions, with a mean diameter of 17 mm (median 16 mm; range, 5–35 mm), and 3(23.1%) CBD wall thickening. Twelve (92%) strictures were hypoechoic, 1(8%) was isoechoic. EUS-TA was performed in all pts, revealing 7(54%) cases of malignancies, of whome 5 cholangiocarcinoma and 2 pancreatic ductal adenocarcinoma (PDAC), 3(23%) high-grade dysplasia, and 3(23%) fibroinflammatory disease on histopatological evaluation. All pts underwent DFI-EUS. Microvascularization was detected in 12 cases (92%), with an irregular pattern observed in 9 pts. Among these, 5 (55.6%) were diagnosed with cholangiocarcinoma, 1(11.1%) with PDAC infiltrating CBD, and 3(33.3%) with high-grade dysplasia. The 3 benign strictures demonstrated a homogeneous pattern. One case (8%), corresponding to a PDAC, appeared hypovascular on DFI.

Conclusion

In a small cohort of patients with unexplained or indeterminate biliary strictures, the novel DFI-EUS technique proved to be feasible for assessing microvascularization in CBD stenosis and revealed characteristic irregular patterns or hypovascularization in malignant lesions. Further prospective studies with a larger patient population are needed to confirm these preliminary findings.

References

1. Facciorusso, A. et al. Diagnostic work-up of bile duct strictures: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 57, 166–185 (2025).
2. Zhang, W., Chai, N., Wu, Q. & Linghu, E. The new criteria for differential diagnosis of indeterminate biliary stricture under super minimally invasive peroral cholangioscopy. Chin Med J (Engl) 137, 255–256 (2024).
3. Yamashita, Y. et al. A Novel Endoscopic Ultrasonography Imaging Technique for Depicting Microcirculation in Pancreatobiliary Lesions without the Need for Contrast-Enhancement: A Prospective Exploratory Study. Diagnostics 11, 2018 (2021).
4. Yamashita, Y. et al. Novel Technique of Endoscopic Ultrasonography for the Differential Diagnosis of Gallbladder Lesions and Intraductal Papillary Mucinous Neoplasms: A Single-Center Prospective Study. Diagnostics 13, 2132 (2023).

Introduction

Avoidant Restrictive Food Intake Disorder (ARFID) is increasingly recognized within the paediatric population and specialist clinics. However, there is sparse data on the prevalence and burden of ARFID within the adult general population. We addressed this issue.

Aims & Methods

A population-based Internet survey with pre-defined demographic quotas was conducted across the UK and USA in 2023. The survey collected data on demographics, body mass index (BMI), ARFID (using the nine-item ARFID screening tool, NIAS), disorders of gut-brain interaction (using the Rome IV diagnostic questionnaire), PHQ-15 somatic symptoms, PHQ-4 anxiety and depression, PROMIS-10 quality of life, and healthcare utilisation.

Results

In total, 4002 adults (mean age 47 [range 18-91] years and 50% females) completed the survey. Overall, 26.0% (n=1035) screened positive for ARFID, with similar results between the UK (23.0%) and USA (29.0%). The prevalence of positive ARFID screens by NIAS subscale were 15.3% for poor appetite, 13.9% for picky eating, and 6.2% for fear of aversive consequences. In all, 18.2% had a single ARFID domain, 5.7% had two domains and 1.9% had all three domains.
ARFID was more common in females than males (29.6% vs. 22.1%, OR 1.5), and highest amongst people aged 18-39 years (31.6%), followed by those aged 40-64 years (25.0%), and lowest in those 65 years and over (16.1%); p<0.001.
Individuals with ARFID - compared to those without ARFID - had a significantly higher prevalence of disorders of gut-brain interaction (51% vs. 37.5%, OR 2.2), including irritable bowel syndrome (11.8% vs. 4.0%, OR 3.2) and functional dyspepsia (25.8% vs. 7.0%, OR 4.6). They were significantly more likely to be underweight (BMI<18.5; 7.0% vs. 1.5%), experience greater somatic symptoms and mood disturbances, reduced mental and physical quality of life, and increased healthcare utilization (i.e. medication use and doctor visits). An increase in the number of ARFID domains was associated with greater general health impairment; p<0.001.

Conclusion

Elevated ARFID symptoms are common within the adult general population, affecting 1-in-4 people, and associated with substantial health burden. Increased awareness of ARFID will aid clinical service provision and future research on how to best manage this patient group.

Disclosure

Nil