Introduction

The necessity and diagnostic yield of routine gastroscopy in Fecal Immunochemical Test (FIT)-positive patients with normal colonoscopy findings remains controversial and poorly defined.

Aims & Methods

Here, we aimed to investigate the prevalence and clinical significance of upper gastrointestinal lesions detected by gastroscopy in FIT-positive patients, stratified by normal and abnormal colonoscopy findings.
This retrospective multicenter study included 38,392 adults (≥18 years) who tested positive for FIT between January 2016 and December 2022 across eight medical centers in Israel. Of them,1,560 patients underwent routine bi-directional endoscopic evaluation and were included in the final analysis. Comprehensive procedural data were retrieved, including detailed colonoscopic and gastroscopic findings. Colonoscopy outcomes included detecting neoplastic and precancerous lesions, with adenoma detection rate (ADR) and polyp detection rate (PDR) calculated. Gastroscopy findings such as gastritis, hiatal hernia, esophagitis, duodenitis, peptic ulcer disease, and malignancy were analyzed and compared between patients with normal and abnormal colonoscopy results.

Results

Among the 1,560 patients undergoing both procedures, 40.5% (n = 632) had normal colonoscopy findings, while 59.5% (n = 928) had abnormal colonoscopy findings. Gastroscopy revealed upper GI findings in both groups, with gastritis detected in 55.1% (normal colonoscopy) vs. 48.7% (abnormal colonoscopy), hiatal hernia in 14.8% vs. 14.9%, esophagitis in 9.0% vs. 10.3%, and duodenitis in 6.6% vs. 7.3%. Clinically Significant findings, such as gastric ulcers, were rare, observed in 0.95% of patients with normal colonoscopy and 1.29% with abnormal colonoscopy. No cases of upper gastrointestinal malignancy were detected in either group.

Conclusion

Routine gastroscopy in FIT-positive patients demonstrates limited diagnostic yield, with clinically significant upper gastrointestinal lesions being rare. Therefore, gastroscopy should be selectively considered based on individual clinical assessment and patient-specific risk factors.

Introduction

Recent advances in large language models, such as GPT-4.0 and GPT-4.5, have increased the accessibility of artificial intelligence (AI) in clinical settings. However, its role in decision-making remains unclear.

Aims & Methods

This study compares the appropriateness of esophagogastroduodenoscopy (EGD) prescriptions across ten clinical scenarios, as evaluated by gastroenterology specialists, residents, general practitioners, and five AI systems (ChatGPT-4.0, ChatGPT-4.5, Gemini, Claude, and OpenEvidence), using ESGE and ASGE guidelines as the reference standard. A cross-sectional survey was developed using 10 real-world clinical vignettes in gastroenterology, each with three response options: appropriate, inappropriate, or uncertain. The vignettes were developed based on real-world clinical practices by three expert gastroenterologists, and then reviewed by the authors.The final questionnaire was hosted on Google Forms and simultaneously distributed—without prior notice—to gastroenterology specialists, residents, and general practitioners across Italy to minimize external influence. The same clinical scenarios were then submitted to five AI systems (ChatGPT-4.0, ChatGPT-4.5, Gemini, Claude, and OpenEvidence) using the same multiple-choice format. AI responses were collected on April 22, 2025.

Results

A total of 122 healthcare professionals participated in the study (61% male; mean age 39.7 ± 13.6), including 41 gastroenterology specialists, 31 residents, and 50 general practitioners. Most participants were from northern Italy (76%), with additional representation from central (14%) and southern regions (10%), covering a total of 10 regions. The majority had less than 5 years of clinical experience (66%) and were employed in public hospitals (49%). Only 30% reported prior use of AI in clinical practice. All respondents considered the clinical scenarios realistic.
The average accuracy rate was highest among gastroenterologists (65.6% ± 11.6) and residents (64.8% ± 10.0), compared to general practitioners (56.8% ± 11.0), with statistically significant differences (p < 0.001 and p < 0.005, respectively).
Among AI systems, OpenEvidence and Gemini outperformed all human groups (80% and 80%, p < 0.001), while ChatGPT-4.0 (70%) and Claude (60%) showed comparable performance to clinicians. Notably, ChatGPT-4.5 (50%) underperformed relative to all human categories.

Conclusion

This study highlights significant variability in the appropriateness of upper GI endoscopy prescriptions among different medical professionals, with gastroenterologists performing better than general practitioners. Emerging AI models, particularly OpenEvidence and GEMINI, demonstrated promising performance in clinical decision-making, outperforming all human groups in certain scenarios. These AI systems could serve as valuable tools to support gastroenterologists and other healthcare professionals, enhancing adherence to evidence-based practices and facilitating more direct consultation of clinical guidelines. Further research is needed to explore the integration of AI into clinical workflows and its potential to refine decision-making in gastroenterology.

References

1) Chang PW, Amini MM, Davis RO, et al. ChatGPT4 Outperforms Endoscopists for Determination of Postcolonoscopy Rescreening and Surveillance Recommendations. Clin Gastroenterol Hepatol. 2024 Sep;22(9):1917-1925.e17. doi: 10.1016/j.cgh.2024.04.022. Epub 2024 May 9. PMID: 38729387.
2) Maida M, Celsa C, Lau LHS, et al. The Application of Large Language Models in Gastroenterology: A Review of the Literature. Cancers (Basel). 2024 Sep 28;16(19):3328. doi: 10.3390/cancers16193328. PMID: 39409948; PMCID: PMC11475222.

Introduction

Endoscopic submucosal dissection (ESD) is being increasingly adopted worldwide for the treatment of colorectal neoplastic lesions. However, its role in patients with inflammatory bowel disease (IBD) remains debatable, particularly due to the increased risk of submucosal fibrosis from chronic inflammation, which can theoretically impact the clinical outcomes of this technique. This study aimed to assess the efficacy and safety of ESD for colorectal neoplastic lesions in IBD patients, comparing Asian and Western settings.

Aims & Methods

A systematic review was conducted by searching MEDLINE and Web of Science until January 2025, in accordance to MOOSE guidelines. We included primary studies reporting ESD performance in IBD patients. We performed random-effects meta-analysis for several outcomes, including en-bloc, R0, and curative resection rates, frequency of adverse events (post-procedural bleeding and perforation), local recurrence and need for additional surgery after ESD. Certainty of evidence was assessed using GRADE.

Results

We included 20 studies (565 patients and 732 lesions). The meta-analytical frequencies of en-bloc, R0, and curative resection rates were 95.7% (95%CI=93.5-97.9%; I²=60.1%), 84.6% (95%CI=79.4-90.1%; I²=68.9%), and 83.9% (95%CI=76.3-92.4%; I²=75.9%), respectively. Bleeding and perforation occurred in 7.0% (95%CI=4.4-11.2%; I²=16.9%) and 7.9% (95%CI=5.3-11.9%; I²=2.4%) of cases, respectively. Local recurrence frequency was 5.3% (95%CI=3.5-7.9%; I²=0%). The meta-analytical need for additional surgery was 13.3% (95%CI=9.5-18.1%; I²=42.5%). No differences were found between Asian and Western studies for any outcome. The certainty of evidence was considered "low" in 4 outcomes and "very low" in the remaining outcomes.

Conclusion

ESD appears feasible and safe for treating IBD-associated colorectal neoplasias. Similar results were observed between Asian and Western studies.

Introduction

Lynch syndrome (LS) is associated with an increased risk of upper gastrointestinal (GI) cancers. While upper GI surveillance is recommended in several guidelines, there remains international variability and ongoing debate regarding its implementation, timing, and extent. This study evaluated the incidence of gastric (GC), duodenal (DC), and jejunal cancers (JC) in LS patients using data from the German Consortium for Familial Intestinal Cancer (GCFIC). In addition, the diagnostic yield of esophagogastroduodenoscopy (EGD) and push enteroscopy (PE), performed at a tertiary care center, was retrospectively analyzed.

Aims & Methods

A total of 960 endoscopic procedures (494 EGD, 466 PE) were retrospectively analyzed in 349 LS patients documented at a tertiary care center. Push enteroscopy (PE) was performed using a colonoscope to allow deeper insertion into the small intestine, enabling inspection of the proximal jejunum. Clinically relevant findings included intestinal metaplasia, Barrett’s esophagus, adenomas, and carcinomas. These findings were systematically compared between EGD and PE to evaluate diagnostic yield. The GCFIC database was evaluated to determine cancer incidence by genotype.

Results

In the GCFIC cohort (n=2859), the majority of GC (2.2%), DC (2.1%), and JC (1.9%) occurred in high-risk pathogenic variant carriers (PGV) (MLH1, MSH2, EPCAM). However, a small proportion of cancers was also observed in low-risk PGV carriers: GC in two MSH6 carriers, DC in five patients with MSH6 or PMS2, and JC in seven low-risk carriers (MSH6: 3, PMS2: 4). In the NZET cohort, 22% of procedures and 50 % of patients revealed relevant findings. Gastric adenomas were found in 3.7%, gastric cancer in 1.1%, and intestinal metaplasia in 28% of patients. Duodenal adenomas were found in 3.7% and cancer in 0.9%. Jejunal neoplasia was detected exclusively by PE (adenomas 1.7%, cancer 0.6%).

Conclusion

Upper gastrointestinal surveillance is essential in patients with Lynch syndrome. Push enteroscopy (PE) provides diagnostic value beyond conventional esophagogastroduodenoscopy (EGD), particularly in detecting jejunal neoplasia, and should be considered in high-risk surveillance protocols.

Disclosure

Robert Hüneburg was funded by Deutsche Krebshilfe (DECADE), and Wilhelm-Sander-Stiftung.
Jacob Nattermann was funded by Wilhelm-Sander-Stiftung.

Introduction

Minocycline is considered the most potent semi-synthetic tetracycline, demonstrates promising pharmacokinetic and antimicrobial properties against Helicobacter pylori (H. pylori). While previous studies suggested the efficacy of minocycline-containing bismuth quadruple therapy for H. pylori eradication, real-world evidence remains limited.

Aims & Methods

his study aimed to evaluate the clinical efficacy, safety, and cost-effectiveness of minocycline-containing bismuth quadruple therapy in routine clinical practice.This multicenter, real-world observational study was conducted at 25 hospitals in Fujian China between January and March 2025. Patients diagnosed with H. pylori infection received one of three 14-day bismuth-containing quadruple regimens with b.i.d. esomeprazole 20 mg and bismuth 220 mg, plus amoxicillin 1000 mg b.i.d. and clarithromycin 250 mg b.i.d. (PBAC), or minocycline 100 mg b.i.d. and clarithromycin 250 mg b.i.d. (PBMC), or minocycline 100 mg twice b.i.d. and levofloxacin 500mg q.d. (PBML). The primary outcome was the H. pylori eradication rate, secondary outcomes included the frequency of adverse events, patient compliance, and cost-effectiveness.

Results

A total of 347 patients were enrolled, with 110 patients completing treatment in each group. In the intention-to-treat (ITT) analysis, eradication rates were 77.4% (PBAC), 85.5% (PBMC), and 84.3% (PBML). In the per-protocol (PP) analysis, eradication rates were 80.9%, 90.9%, and 88.2%, respectively. Although the differences among the three regimens were not statistically significant, minocycline-based regimens achieved numerically higher eradication rates. Adverse event incidence was 32.73%, 20.91%, and 23.64% in the three groups, respectively. Compliance rates exceeded 94% across all groups. Cost-effectiveness analysis showed PBML had the lowest cost-effectiveness ratio (5.38 CNY per 1% eradication), followed by PBAC (5.41 CNY) and PBMC (6.06 CNY).

Conclusion

H. pylori eradication, with favorable patient compliance and pharmacoeconomic profiles. These regimens present a viable alternative to traditional amoxicillin-or tetracycline-based therapies. Further large-scale randomized controlled trials are warranted to confirm these findings.

Clinical Case Summary

A 57 years-old patient with a history of active smoking, moderate body overweight (BMI 29 Kg/mq) and mild systolic hypertension in treatment with Olmesartan complained history of chronic diarrea and abdominal pain since 2006, rarely associated with hematochezia. After replacement of antihypertensive therapy to eliminate a potential confouding factor, he underwent multiple colonoscopies through the years with nonspecific findings until 2017, when moderated discontinuos inflammation with multiple erosions was seen in the transverse colon and in the rectum. Histologic examination described presence of chronic inflammation with cryptic microabscesses and cryptitis suggetive for Crohn's disease, while intestinal ultrasound revealed no small bowel localizations. He was treated with 2.4 daily grams of oral mesalamine with benefit until the end of 2023, when he came up to our clinic complaining resumption of bloody diarrhoea and abdominal pain, with 3-4 liquid stools per day. Addition of topic mesalamine was not of benefit. The patient underwent another colonoscopy which confirmed presence of hyperemic mucosa with diffuse erosions in the rectum, with histology confirming active Inflammatory Bowel Disease. In march 2024, after neurological investigations for recurrent paresthesias and strength deficits, the patient was diagnosed with relapsing-remitting Multiple Sclerosis. After multidisciplinary consultation, negative cardiologic evaluation, chest X-ray and blood screening exams, in October 2024 the patient started the anti sphingosine-1 phosphate Ozanimod, which was well-tolerated at maintenance dose of 0.92 milligrams per day. Three months after, he came back for scheduled follow-up reporting 1 or 2 daily evacuations in absence of abdominal pain and rectal bleeding. Calprotectin levels droped up to 17 ug/g. He also described complete neurological remission and complete absence of drug side effects.

References

1) Feagan BG, Schreiber S, Afzali A, Rieder F, Hyams J, Kollengode K, Pearlman J, Son V, Marta C, Wolf DC, D'Haens GG. Ozanimod as a novel oral small molecule therapy for the treatment of Crohn's disease: The YELLOWSTONE clinical trial program. Contemp Clin Trials. 2022 Nov;122:106958.
2) Pérez-Jeldres T, Alvarez-Lobos M, Rivera-Nieves J. Targeting Sphingosine-1-Phosphate Signaling in Immune-Mediated Diseases: Beyond Multiple Sclerosis. Drugs. 2021 Jun;81(9):985-1002. Erratum in: Drugs. 2021 Aug;81(12):1451.
3) Harris S, Feagan BG, Hanauer S, Vermeire S, Ghosh S, Yan J, Wu C, Hu Y, Maddux R, Wolf DC, D'Haens G. Ozanimod Differentially Impacts Circulating Lymphocyte Subsets in Patients with Moderately to Severely Active Crohn's Disease. Dig Dis Sci. 2024 Jun;69(6):2044-2054.
4) Sands BE. Positioning Sphingosine-1 Phosphate Receptor Modulators in Inflammatory Bowel Disease. Gastroenterol Hepatol (N Y). 2024 Jul;20(7):417-420.
5) Cree BA, Selmaj KW, Steinman L, Comi G, Bar-Or A, Arnold DL, Hartung HP, Montalbán X, Havrdová EK, Sheffield JK, Minton N, Cheng CY, Silva D, Kappos L, Cohen JA. Long-term safety and efficacy of ozanimod in relapsing multiple sclerosis: Up to 5 years of follow-up in the DAYBREAK open-label extension trial. Mult Scler. 2022 Oct;28(12):1944-1962. doi: 10.1177/13524585221102584. Epub 2022 Jun 28. Erratum in: Mult Scler. 2022.