Introduction

Low fermentable oligo-, di-, and monosaccharides and polyol (FODMAP) diet is currently recommended for the treatment of irritable bowel syndrome (IBS). However, long-term adherence is not high due to its complex nature.
Recently, ChatGPT (OpenAI, San Francisco, California, USA), a large scale unsupervised language model, was introduced as an easily accessible internet based chat, and demonstrated unprecedented capabilities of processing natural conversations and the ability to provide insightful and comprehensive replies.

Aims & Methods

In this brief proof of concept study, we aimed to evaluate the feasibility of using ChatGPT as a readily available guide for adherence to a low FODMAP diet.
We presented ChatGPT with 3 sets of questions concerned with low FODMAP:
(1) 10 questions in the form of “is Bⁱ low FODMAP” were prompted to ChatGPT in which Bⁱ is the i element of a list of 10 base products, 5 of which are considered low FODMAP, and 5 high FODMAP; We chose base products upon which there was unanimous agreement among different available lists of FODMAP-containing foods.
(2) 10 questions in the form of “is Dⁱ low FODMAP” were prompted to ChatGPT in which Dⁱ is the i element of a list of 10 popular dishes, 5 of which are considered low FODMAP, and 5 high FODMAP
(3) 7 questions in the form of “suggest a low FODMAP Cⁱ recipe” were prompted to ChatGPT in which Cⁱ is the I course of a traditional 7 course meal.
Questions and answers were then presented to two dietitians from our gastroenterology institute (M.D and C.P), both experienced in the care of IBS patients and low FODMAP guidance.
Dietitians were independently asked to grade each answer as correct or incorrect, and check whether they would use this answer as future recommendation for patients.

Results

A complete agreement between the two dietitians was observed (100% same review of chatGPT answers).
Out of the 27 submitted questions, 22 answers were reviewed as correct (81%).
From the 5 answers that were deemed as wrong, 4 (80%) were from the base products list, and 3 of these 4 were of high FODMAP base products. The additional wrong answer was from the popular dishes list, in which, a dish that contained high FODMAP ingredients was suggested as low FODMAP by the ChatGPT answer.
In the dishes and recipes section ChatGPT provided suggestions for alternative ingredients and food preparation techniques that would make the dishes low FODMAP. All the suggestions were deemed as correct by both dietitians.

Conclusion

ChatGPT perfomed well in answering questions regarding low FODMAP diet. It could possibly be used as an auxiliary tool for daily decisions on low FODMAP diet.

Introduction

Dietary regimens for symptom management in irritable bowel syndrome (IBS) include a low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) diet and a gluten-free diet. However, scientific evidence supporting these dietary recommendations for managing IBS symptoms is weak: trials have been non-blinded and underpowered, while mechanistic understanding and objective markers of response remain scarce.

Aims & Methods

We therefore conducted a large double-blind study to investigate the effect of FODMAPs and gluten on symptomatic and molecular data including gut microbiota and the metabolome, both at a group and subgroup (differential response) level. Moreover, the accuracy of the Bristol Stool Form Scale (BSFS) used in IBS subtype diagnosis was assessed, and thus overcome the lack of objective evaluation of IBS symptoms. The results were recently collected in a doctoral thesis.

Results

Trial data revealed that gluten caused no symptoms and that FODMAPs triggered only modest symptoms of IBS. Subjective reporting according to the BSFS conformed only modestly with stool water content. FODMAPs increased saccharolytic microbial genera, phenolic-derived metabolites and 3-indolepropionate, but decreased bile acids. Saccharolytic genera correlated with increased plasma concentrations of phenolic-derived metabolites and 3-indolepropionate, metabolites related to decreased risk of incident type 2 diabetes and inflammation. Indeed, among FODMAP-related metabolites, only weak correlations to IBS symptoms were detected, as with 3-indolepropionate to abdominal pain and interference with quality of life, warranting further investigation. Gluten displayed a modest effect on metabolites involved in lipid metabolism, but with no interpretable link to health. No molecular biomarkers of a differential response to the challenges were found, despite comprehensive exploration with multiple analytical approaches. This could be explained by the absence of baseline variables, such as other omics layers or psychological factors, that could have determined the difference.

Conclusion

Diet only had a modest effect on IBS symptoms. Caution should be taken when subtyping IBS with BSFS.

Introduction

Enteroscopy is an established method for endoscopic diagnosis and interventions in the small intestine. Currently, there are three procedures available: single-balloon enteroscopy, double-balloon enteroscopy, and motorized spiral enteroscopy. Recent studies have shown that motorized spiral enteroscopy is very effective but also associated with more complications. There are no comparative studies between double-balloon and motorized spiral enteroscopy.

Aims & Methods

This randomized, prospective trial was conducted at two tertiary centers. All consecutive patients with an indication for enteroscopy were asked to participate in the study. Patients were randomly assigned to the motorized spiral or double-balloon arm after being informed. The examination was then performed with the respective procedure.
This study aims to compare the effectiveness of the new motorized spiral enteroscopy with double-balloon enteroscopy. The time to diagnosis or complete enteroscopy and possible complications of both procedures were investigated.

Results

39 enteroscopies (19 motorized spiral, 20 double-balloon) were performed in 36 patients. In the spiral group, access was achieved orally in 58% of cases. A complete enteroscopy was possible in 26% of cases with a median time of 36 minutes. In 16%, a complete enteroscopy was possible via the oral route. In the double-balloon group, access was achieved orally in 85% of cases. A complete enteroscopy was possible in 10% of cases with a median time of 45 minutes. In 5%, a complete enteroscopy was possible via the oral route. Diagnostic yield was higher in double balloon enteroscopy compared to spiral enteroscopy with positive findings in 75% and 32% respectively. There was one perforation in the motorized spiral group. There were no severe complications in the balloon group.

Conclusion

Motorized spiral enteroscopy seems to be more effective in terms of speed and depth. However, it is also associated with more complications

Introduction

Digestive hemorrhage is a frequent complication in advanced chronic kidney disease. Patients with end-stage renal disease (ESRD) are more likely to have gastrointestinal (GI) problems, including digestive bleeding of high or low origin.

Aims & Methods

The aim of our work is to study the particularities of HD in CKD patients.
This is a monocentric prospective analytical study over a period of 28 months: April 2020 to August 2022, including patients with HD with CKD at the dialysis stage or not, including renal transplant patients.
In order to be able to compare patients with ESRD with patients without ESRD, a control group of patients admitted for HD who had a GI endoscopy during the study period and with normal renal function were identified and grouped. In this group of patients, we took into account age, sex, indications, GI endoscopy results and ICU stay.
We also assessed all-cause mortality between the groups of CKD patients with HD versus the control group.

Results

A total of 378 patients underwent digestive exploration for HD. In this population, 46 (12.16%) patients with CKD were compared with 332 patients without RI.
70% (n=32) of the patients with RI were on chronic hemodialysis, 26% (n=12) had a GFR<60ml/min/1.73m2 but were managed without the aid of dialysis or transplantation, and 4% (n=2) patients were renal transplant recipients.
The most common etiologies in CKD patients were ulcer disease 65.2% (n=30); vascular ectasia 28.2% (n=13), gastritis 26% (n=12), esophagitis 10.8% (n=5); and tumors in 8.6% (n=4).
After statistical analysis patients with CKD had:
A higher risk of hemodynamic instability 69.5% (n=32) compared to the control group 11.14% (n=37) with p=0.002,
A higher rate of recurrence 26% (n=12) CKD patients compared to 9.6% (n=32) of the control group with a p=0.00.
A higher mortality rate 4.34% (n=2) in CKD patients compared to the control group 1.2% (n=4) with p=0.00.

Conclusion

GI bleeding in advanced chronic kidney disease is more severe it is accompanied by a higher risk of recurrence of ICU stay and mortality, hence the interest of prompt management and close monitoring. The main causes are peptic ulcer and vascular ectasia.

Introduction

The indications for colonoscopy are clearly defined and its main objective is to look for neoplasia or lesions at high risk of colorectal neoplasia, even if benign lesions are much more frequent. Common indications for young adults < 50 years include rectal bleeding and diarrhea, while for subjects over 50 years, the indications may be larger given the risk of colorectal cancer, despite the recent increase in neoplastic lesions in young adults.

Aims & Methods

A retrospective descriptive and analytical study, including 1518 patients, was carried out over 3 and a half years. The patients were divided into 2 groups: group A for patients aged less than 50 years, and group B for patients aged greater than 50 years. We compared epidemiological, clinical, and endoscopic data between the two groups. Patients known to have inflammatory bowel disease (IBD) were excluded from our study. The statistical analysis was carried out by the JAMOVI software.
Our study aims to compare the indications and results of colonoscopy between those under and over 50 years old and to determine the indications associated with a risk of neoplastic lesion.

Results

65.1% of patients were over 50 years old, and 34.9% were under 50 years old. The average age was 37.5 ± 9 years in group A and 64.4 ± 9 years in group B. The female gender predominated among those under 50 years old (55.3%), while the male gender predominated among those over 50 years old (56.3%) (p<0.001).
History of colorectal cancer predominated among those over 50 years old at 10.5% (vs 4.4%; p<0.001). The indications for colonoscopy were dominated by constipation in patients in group B at 29.1% (vs 22%; p=0.01) and by diarrhea in patients in group A at 33.3% (vs 19. 3%; p<0.001).
Colonoscopy was pathological in 49.1% of patients in group B vs 32.9% of patients in group A (p<0.001). It was dominated by colitis or rectocolitis (47.9%) in subjects under 50 years old (vs 11.7%; p<0.001), by polyps (61.5% vs 41.3%; p<0.001) and colorectal neoplasia (16% vs 5%; p=0.002) in older patients.
A higher risk of neoplastic lesions was associated with rectal bleeding and constipation (p < 0.001) in subjects > 50 years old, and with constipation in subjects < 50 years old (p = 0.007).

Conclusion

The presence of neoplastic lesions was strongly associated with the presence of constipation in subjects < 50 years old and with rectal bleeding and constipation in subjects > 50 years old. Early screening with colonoscopy might be beneficial for young individuals with these higher-risk lesions of colorectal cancer.

Introduction

EUS-guided portal pressure gradient measurement (EUS-PPGm) would be a useful procedure in patients with liver diseases (1). However, there is scarcely data on the clinical relevance of this EUS-guided procedure.

Aims & Methods

We report our experience on EUS-PPGm focus on safety, clinical relevant findings, technical drawbacks and how to overcome them.
We used a therapeutic echoendoscope and a 25G dedicated needle as previously reported (1, 2). To minimize the risk of infection, periprocedural antibiotherapy was administered and the working channel of the echoendoscope was flushed with povidone-iodine.

Results

EUS-PPGm was performed in 30 patients, median age 42±3 yo. Indications: assessment of NAFLD, 25 patients; idiopathic portal hypertension, 3 patients; evaluation for curative therapy in hepatocellular carcinoma (HCC), 2 patients. Anticoagulants were withdrawn in 4 patients. EUS-guided bilobar liver biopsies (EUS-BLB) were also immediately performed in 26 patients (87%) with a 19G needle. EUS-PPGm was successfully obtained in 25/30 patients (83%). EUS-PPGm was >5 mmHg in 14/25 cases (56%). In idiopathic portal hypertension 3/3 patients. In NAFLD 10/22 patients (45%) without endoscopic and/or ultrasonographic signs of portal hypertension and without liver fibrosis on EUS-BLB. Mean time to obtain EUS-PPGm was 21±2 minutes. Mean time for EUS-PPGm plus EUS-BLB was 45±2 minutes. Idiopathic portal hypertension was assessed by this procedure with the complementary information given by the EUS-BLB. In the 2 patients with HCC, one patient did not have reliable results and, in the other, EUS-PPGm was useful ruling out portal hypertension and the patient was referred to curative surgery that was successfully carried out.
Technical drawbacks: In 5 cases (17%) EUS-PPGm was not obtained due to non-reliable measurements in 4 cases probably due to excesive use of the elevator and up&down wheel of the echoendoscope and bending of the needle, that would be avoided. In the fifth case the EUS-PPGm was not performed for exacerbating breathing movements that precluded the procedure for safety concerns. We experienced difficulty in punctioning the hepatic and the portal vein in one and two cases, respectively, having to transverse these vessels and repositioning the needle in the lumen of these veins. In one case the 25G needle passed in close proximity to the hepatic artery. We think dedicated 25G needles have more flexibility and penetrability than larger caliber needles and, probably could lead for a safer and easier procedure and could be more accurate in the puncture of narrow vessels in liver cirrhosis (3).
Adverse events: A self-limited bleeding from the cardias was immediately observed after one EUS-PPGm in a patient with idiopathic portal hypertension. One mild epigastric pain 2 day after a combined procedure was observed. No other adverse events were registered one month later.

Conclusion

EUS-guided PPGm, even when combined with EUS-BLB, seems safe providing useful clinical information. Almost half of patients affected with NAFLD have portal hypertension diagnosed precociously in reversible stages providing a useful tool in precision Medicine, especially in the setting of obesity pandemic. Idiopathic portal hypertension was confirmed by this procedure with the complementary information provided by the EUS-BLB. In the patient with HCC, EUS-PPGm rule out portal hypertension and allowed for curative surgery. There are technical aspects related to the needle and the position of the echoendoscope that could be useful to know to improve the safety and accuracy of this procedure.

References

(1) Samarasena J, Chang KJ. Endo-hepatology: A new paradigm. Endosc Ultrasound. 72018. p. 219-22.
(2) Hashimoto R, Chang KJ. Endoscopic ultrasound guided hepatic interventions. Dig Endosc. 2021;33(1):54-65.
(3) Romero-Castro, R; Carmona-Soria, I; Jimenez-Garcia, VA; et al. Endoscopic ultrasound-guided portal pressure gradient measurement: Improving its safety overcoming technical drawbacks. Endoscopy (In press).

Disclosure

Rafael Romero-Castro is consultant to Cook Medical since February, 28th, 2023.