Introduction

Dysbiosis of the microbiome is associated with inflammatory bowel diseases (IBD), including Crohn’s disease (CD) and ulcerative colitis (UC), the two major forms of IBD. However, data are scarce and primarily limited to animal studies

Aims & Methods

We aimed to assess if stool microbiome characteristics are associated with disease severity, disease location, and inflammatory pathways using microbiome data obtained from the Study of a Prospective Adult Research Cohort with IBD (SPARC IBD) obtained from the IBD Plexus program of the Crohn’s & Colitis Foundation for 926 CD and 491 UC patients. Characterization of stool shotgun metagenomics was conducted with MetaPhlAn2 and HUMAnN2 to determine abundance of taxa and functional pathways, respectively. ANOVA and linear regression analyses were conducted to associate bacterial composition and functional potential with the selected clinical and exploratory measures. Mucosal inflammation was assessed with mucosal transcriptome data.

Results

Most of the samples came from Caucasians and females, and approximately 70% patients were in remission. 295 of 727 patients with CD had disease location data and 83% of these patients had ileal involvement (Table 1). We observed distinct microbial profiles between patients with active disease versus inactive disease in both CD and UC. Specifically, oral commensals belonging to Veillonella, Klebsiella, Rothia, and Megasphaera were more abundant in patients with active disease in both CD and UC, while 21 genera including butyrate producing species belonging to Anaerostipes, Ruthenibacterium, Faecalibacterium and Roseburia were more abundant in patients with inactive disease in both CD and UC. We also noted differences in relative abundances of bacterial taxa by disease activity separately within UC and CD. In UC, the fecal microbial signatures with active disease were enriched with Escherichia, Haemophilus, and Anaerococcus, while Lactococcus, Proteobacteria_unclassified, Parasutterella, and Gemella were more abundant in patients with inactive disease. In CD, 9 unique genera were more abundant in patients with active disease, and 24 unique genera were more abundant in patients with inactive disease, consistent with the fact that CD manifests in both isolated disease locations (ileum or colon) or a combination of locations (ileocolonic) and UC is limited to the colon and the rectum. Indeed, 32 out of the 33 genera specific to CD, but not UC, were found to be associated with altered enrichment in ileal or ileocolonic CD compared to colonic CD, when stratifying by disease location.

Table 1 Population characteristics including disease activity (CD and UC) and CD disease location

Conclusion

Differences in microbiota by disease location suggest separate location-specific pathologies. Location-specific interactions between host intestinal gene expressions and microbiota, suggest key immune-mediated molecular pathways and relevant bacteria in intestinal tissue, which may guide drug development and precision medicine in IBD.

Disclosure

Christopher Morehouse, Ben Sparklin, Bret Sellman, Antonio DiGiandomenico, Vancheswaran Gopalakrishnan, Bastian Angermann, Ulf Gehrmann, Jessica Neisen, Emon Khan and Junmei Cairns are all employees of AstraZeneca.

Introduction

The mainstay of treatment of Zenker’s diverticulum is cricopharyngeal myotomy. Although flexible endoscopic septotomy is widely implemented, complete myotomy is difficult to assess resulting in recurrence rates of 11%. On the other hand, ZD peroral endoscopic myotomy allows complete myotomy visual confirmation, at the expense of procedure length and complexity. To overcome these limitations, a hybrid technique that allies FES simplicity and fastness to zPOEM efficacy is proposed: 1-septum isolation with overtube; 2-standard FES until middle of the diverticulum; 3-muscular septum isolation by zPOEM until the base of the diverticulum; 4-complete myotomy; 5-residual mucosal flaps section; 6-mucosotomy closure with TTS clips. We aim to demonstrate the feasibility, effectiveness and safety of the hybrid zPOEM technique for the treatment of ZD.

Aims & Methods

A retrospective analysis including patients with ZD treated by hybrid zPOEM procedure from April 2021 to February 2023 was made. Technical success, early clinical success (dysphagia score ≤ 1), adverse events and recurrence rates were evaluated.

Results

11 patients (male 54.5%, mean age 72.9 years) underwent hybrid zPOEM procedure for treatment of ZD (mean size 23.18mm, range 15-30mm). The procedure was technically successful in all patients, with a mean procedure time of 21.6 minutes. Early clinical success was achieved in all patients, although 1 patient maintained occasional regurgitation due to incomplete mucosal flaps section. Mean symptoms scores improved from baseline for dysphagia (1.5 vs 0), regurgitation (1.5 vs 0.1), halitosis (0.5 vs 0), cough (0.5 vs 0) and hoarseness (0.3 vs 0). During a mean follow-up time of 10 months, no recurrence was recorded. No intra- or post-procedure AE were recorded.

Conclusion

Hybrid zPOEM technique is a fast, safe and effective procedure, where, by combining classic FES and zPOEM, one can have the best of both techniques. This procedure should be considered as a first-line therapeutic option in third-space-endoscopy experienced centers.

References

Zhang LY, Nieto J, Ngamruengphong S, Repici A, Khashab MA. Zenker’s diverticulum: advancing beyond the tunnel. VideoGIE. 2021;6(12):562–7
Lupu A, Lafeuille P, Yzet C, Benech N, Jacques J, Rivory J, et al. Hybrid peroral endoscopic myotomy for large Zenker’s diverticulum. Endoscopy. 2022;54:E862–3.
Krishnan A, Ichkhanian Y, Runge TM, Khashab MA. Hybrid endoscopic approach for submucosal tunneling septum division for Zenker s diverticulum. Endoscopy. 2020;52(12):E457–8.

Introduction

Per-oral endoscopic myotomy (POEM) is an established treatment modality for achalasia cardia. Submucosal fibrosis (SMF) is rare, but the most important reason for technical failure during POEM. Prediction of SMF may be crucial to improve technical outcomes with POEM.

Aims & Methods

In this study we aim to evaluate the predictors for SMF in cases with achalasia cardia.Consecutive patients with achalasia cardia who underwent POEM (Aug 2021 to October 2022) were included in the study, prospectively. Various factors were analysed for prediction of SMF including age, gender, stasis esophagitis, type of achalasia, duration of disease, lower esophageal sphincter pressure (LESP), height of barium column on barium esophagogram and severity of symptoms (Eckardt score). Esophageal mucosa was graded for the severity of stasis esophagitis (grade I to grade III) based on vascular pattern, mucosal thickening, ulceration and nodularity. SMF was graded (I minimal, II moderate, III severe) according to mucosal lift, difficulty in entry, density of SM fibers, separation of mucosa and muscle.

Results

240 patients (males 139, mean age 44.4±14.7 years) underwent POEM during the study period. The subtypes of achalasia included type I in 29, type II in 201, type III in 10. Median symptom duration was 24 (1-240) months and mean pre-POEM Eckardt score was 7.6±1.8. Majority (93.3%) of the patients were treatment naïve and underwent POEM via posterior route (91.2%). Stasis esophagitis was evident in 122 (50.8%) patients including grade I in 99 (41.3%), grade II in 16 (6.7%) and grade III in 7 (2.9%) patients. SMF was detected in 87 (36.3%) patients including grade I in 52 (21.7%), grade II in 30 (12.5%) and grade III in 5 (2.1%) patients. Mean age, duration of symptoms, width of esophagus and procedure duration were significantly higher in cases with submucosal fibrosis. (Table 1) Significantly higher proportion of patients with type I achalasia (62.1%) had SMF as compared to type II (33.8%) and type III achalasia (10%) [p=0.013]. On multivariate analysis, the presence of stasis esophagitis and width of esophagus on timed barium were predictors of significant (≥grade II) SMF.

Conclusion

Severe SMF (grade III) is uncommon in cases with achalasia cardia. The presence of stasis esophagitis and width of esophagus are predictors of SMF during POEM.

References

1. Wu QN, Xu XY, Zhang XC, Xu MD, Zhang YQ, Chen WF, Cai MY, Qin WZ, Hu JW, Yao LQ, Li QL. Submucosal fibrosis in achalasia patients is a rare cause of aborted peroral endoscopic myotomy procedures. Endoscopy. 2017 Aug;49(08):736-44.
2. Feng X, Linghu E, Chai N, Ding H. New endoscopic classification of esophageal mucosa in achalasia: A predictor for submucosal fibrosis. Saudi journal of gastroenterology: official journal of the Saudi Gastroenterology Association. 2018 Mar;24(2):122.

Disclosure

Nothing to disclose

Introduction

Considering the impaired platelet function in uremic patients, the risk of post-polypectomy bleeding may increase in patients with end-stage renal disease undergoing colonoscopic polypectomy. Nevertheless, little is known about the risk factors of bleeding after colonoscopic polypectomy in these patients. This study investigated the incidence and risk factors of post-polypectomy bleeding, including immediate and delayed bleeding, in patients with end-stage renal disease (ESRD).

Aims & Methods

Ninety-two patients with ESRD who underwent colonoscopic polypectomy between September 2005 and June 2020 at a single tertiary referral center were included. The patients’ medical records were retrospectively reviewed. Patient- and polyp-related factors associated with immediate PPB (IPPB) were analyzed using logistic regression analysis. Additionally, the optimal cutoff polyp size related to a significant increase in the risk of IPPB was determined by performing receiver operating characteristic (ROC) analysis and calculating the area under the ROC curve (AUC).

Results

In total, 286 polyps were removed. IPPB occurred in 24 (26.1%) patients and 46 (16.1%) polyps, and delayed post-polypectomy bleeding occurred in 2 (2.2%) patients. Regarding the hemostasis method for IPPB, clipping was used in 31 (67.4%) cases and a combined method with clipping and coagulation was used in 15 (32.6%) cases. According to multivariate analysis, the polyp size (> 7 mm) (odds ratio=5.259, 95% confidence interval [CI]: 2.367–11.684), old age (>70) (odds ratio=4.186, 95% CI: 2.012–8.708), and endoscopic mucosal resection (EMR) as the polypectomy method (EMR versus non-EMR: odds ratio=3.339, 95% CI: 1.440–7.743) were found to be independent risk factors for IPPB. According to the Youden index method, the optimal cutoff polyp size to identify high-risk polyps for IPPB was 7 mm (AUC=0.755; sensitivity, 76.1%; specificity, 69.6%).

Conclusion

Colonoscopic polypectomy should be performed with caution in patients with ESRD, especially in those with the following risk factors: advanced age (>70 years), polyp size >7 mm, and EMR as the polypectomy method.

Clinical Case Summary

Cronkhite-Canada syndrome (CCS) is a rare gastrointestinal disorder characterized by multiple polyps throughout the digestive tract, often accompanied by ectodermal changes such as onychodystrophy. Here, we present a case of CCS in a 65-year-old female with an unremarkable medical history presented with chronic abdominal pain and diarrhea containing mucus and blood, occurring 3 to 4 times per day. Clinical examination revealed signs consistent with malnutrition. Angular deformities, suggestive of onychodystrophy, were noted, while no other significant gastrointestinal abnormalities were observed.
During physical examination, the patient displayed signs of malnutrition. Abdominal palpation revealed tenderness, particularly in the lower quadrants, without palpable masses or organomegaly. Bowel sounds were present and within normal limits.
Laboratory investigations revealed elevated levels of ferritinemia. Computed tomography revealed three suspicious thickened segments within the digestive tract: one located in the antral region, the second in the cecal region, and the third in the sigmoid region. Colonoscopy demonstrated an erythematous colonic mucosa with polypoid lesions. Pathological examination revealed an illdefined colonic polyp characterized by multiple cystically dilated glands within an edematous lamina propria, accompanied by lymphocytes, plasma cells, and numerous eosinophils, favoring the diagnosis of Cronkhite-Canada syndrome.
This case highlights the importance of considering Cronkhite-Canada syndrome in the differential diagnosis of patients presenting with chronic gastrointestinal symptoms, malnutrition, and onychodystrophy. Early recognition and appropriate management, including nutritional support and surveillance for complications, are crucial in improving outcomes for patients with this rare and challenging syndrome. Further research is needed to better understand the pathogenesis and optimal treatment strategies for Cronkhite-Canada syndrome.

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.