Introduction

The latest ESGE technical review guideline advocates real-time monitoring in the first hour of small bowel capsule endoscopy (SBCE) to ensure entire small bowel visualization. However, a survey demonstrated poor adherence to this statement in clinical practice, and supporting data are scarce.

Aims & Methods

We aimed to evaluate predictive factors of incomplete SBCE and to ascertain the importance and cost-effectiveness of real-time monitoring.
We retrospectively included consecutive patients who ingested SBCE (PillCam SB3) at our tertiary referral center from 2013 to 2020. Clinical and endoscopic characteristics were analyzed. Real-time monitoring was not applied according to local protocol. Prolonged gastric transit time (GTT) was defined when the capsule crossed the pylorus > 2 hours from ingestion, and prolonged small bowel transit time (SBTT) when cecum was reached > 6 hours from pylorus crossing. A logistic regression analysis was done to find significative risk factors associated with incomplete SBCE. Exclusion criteria included: capsule retention, endoscopic delivery of capsule, and major technical issues (i.e., eating within a standard gastric transit time of the capsule or major recording issues).

Results

A total of 859 SBCE were analyzed, with a completion rate of 94.5%. A prolonged GTT and a prolonged SBTT were found in respectively 46 (5.4%) and 152 (17.6%) procedures. At multivariate analysis, one modifiable (prolonged GTT[p=0.02]) and two unmodifiable risk factors (inpatient status [p<0.01] and history of incomplete SBCE [p=0.02]) were associated with a higher rate of incomplete SBCE, with increased odds ratio of 3.0 (CI95%= 1.2-7.4), 2.3 (CI95%= 1.2–4.2), and 3.7 (CI95%= 1.2-11.9), respectively. Pretest probability of SBCE completion rate was 90.5% and 95.7% in patients with and without unmodifiable risk factors (p=0.01).
Considering the rates of prolonged GTT, the number of patients to be monitored with real-time viewer to identify and treat one patient with prolonged GTT is 14.5 in patients with unmodifiable risk factors for incomplete SBCE and 20.3 in patients without risk factors for incomplete SBCE (p=0.27).
Direct cost for 1-hour real-time monitoring and intervention in case of prolonged GTT (i.e., dedicated room, nurse, +/- metoclopramide and IV access) are equal to circa 35 €. If all patients of our cohort would undergo real-time monitoring, the expense would be equal to 30065 €. Given that in our cohort 6 patients had an incomplete SBCE, the cost of RTM to prevent one incomplete SBCE would be equal to 5010 €. If RTM would be limited to patients with unmodifiable risk factors for incomplete SBCE, the total cost would be equal to 6615 €. In this sub-group only 2 patients had an incomplete SBCE, therefore, to prevent one incomplete SBCE, the total expense would be 3307 €.

Conclusion

The inpatient status, a prolonged GTT and a previous incomplete SBCE are risk factors for incomplete SBCE. According to our direct costs analysis, the number needed to treat one prolonged GTT to decrease the rate of incomplete SBCE appears to be cost-effective in patients with unmodifiable risk factors (i.e., inpatient status and history of incomplete SBCE).

Introduction

Collagenous colitis (CC) and lymphocytic colitis (LC), the two main subtypes of microscopic colitis (MC), are chronic inflammatory diseases of the colon of unknown etiology. Colonic barrier dysfunction has been identified in patients with MC. However, whether molecular and structural alterations underlie an aberrant barrier in MC remains to be defined.

Aims & Methods

To identify the molecular pathways involved in the colonic epithelial brush border structure and its ultrastructural alterations in MC. Total RNA and protein were obtained from sigmoid mucosal biopsies of healthy controls (Hc) (N=11), patients with active diarrhoea predominant irritable bowel syndrome (IBS-D) patients (N=13), and active newly diagnosed naive of treatment MC patients (N=12 CC and N=12 LC). Transcriptomic and proteomic analyses were performed by RNAseq analysis and liquid chromatography mass spectrometry, respectively. Additionally, in a subset of patients (N=8 CC, N=8 LC, N=8 IBS-D and N=8 Hc) sigmoid biospies were collected and processed for scanning and transmission electron microscopy (SEM and TEM, respectively), to perform a qualitative and quantitative assessment of the colonic epithelium. Integrated data assessment was performed to explore biological and molecular functions.

Results

By RNA-Seq enrichment study, three microvilli-related pathways (organization, regulation of microvilli organization and length) were significantly enriched in the colonic mucosa of CC patients compared to LC, IBS-D and Hc. The integrated multi-omic analysis identified 28 genes with a significant positive correlation between RNA expression and its corresponding protein expression, (4 genes with a strong correlation (r>0.7, p<0.05) and 21 genes with a moderate correlation (0.3<r<0.7, p<0.05)), which were related to each other at the network level by string database analysis. Reduced expression of the microvilli proteins, was observed in CC compared to Hc, IBS-D and LC patients. Reduced expression of the actin-binding proteins, was also observed in CC. Moreover, decreased protein expression and an increased expression of proteins in the actin-membrane junction, were observed in CC and LC. Ultrastructural observation revealed that microvilli on the colonic surface of MC patients were more scattered, irregular and shorter in MC than IBS-D and Hc. Furthermore, the number of microvilli per colonocyte length (microvilli/um) was lower in CC (3.7[2.8-5.3], p<0.0001) and LC patients (5.2[4.0-6.6], p=0.01) compared to Hc (7.5[6.6-8.7]). Similarly, microvilli length was also reduced in CC (0.5[0.4-0.8], p=0.0003) and LC (0.6[0.4-1.1], p=0.04) patients compared to Hc (1.1[1.0-1.4]). No differences in the number and length of microvilli were observed between IBS-D and Hc groups.

Conclusion

Dysregulated brush border molecular pathways underlie epithelial colonic dysfunction in MC compared to Hc and IBS-D patients at both molecular and ultrastructural levels. These previously undescribed data open new perspectives in defining the pathophysiological mechanisms of MC, especially in CC. Given the fundamental role of the brush border in maintaining intestinal homeostasis and even water absorption, further understanding of these mechanisms may have significant diagnostic and therapeutic implications for MC.

Disclosure

Dr Javier Santos has served as consultant for Noventure SL, Devintecpharma, Reckitt, Ipsen, Aboca & Pileje and discloses present and past recent scientific collaborations with Salvat, Norgine, Alfa-Sigma, Cosmo, Adare, Ordesa and Danone that do not constitute a conflict of interest in developing the content of the present manuscript.

Introduction

Collagenous colitis (CC) is a form of microscopic colitis (MC), the others being lymphocytic colitis (LC), incomplete CC and incomplete LC (1). It is an inflammatory disease of the large bowel that causes chronic watery diarrhoea, abdominal pain, faecal incontinence, nightly defecation, and weight loss, resulting in significantly impaired quality of life (2). Incidence of MC has increased significantly during the past decades in some countries and the main reason for this increase is thought to be an enhanced disease recognition (3). The diagnosis of MC is challenging as it can only be diagnosed upon histological examination of colonic biopsies taken from normal or near normal appearing mucosa (1). Histological interpretation of biopsies involves subjective evaluation leading to inter-rater variability discrepancies in diagnosis and treatment plan. Deep learning-based assistance system can objectivise diagnostic key feature selection leading to minimisation of inter-rater variability and improvement of diagnostic accuracy.

Aims & Methods

The aim of this pilot study was to develop an algorithm for robust segmentation of light microscopy images of histological specimen slides (tissue slides) emphasizing key diagnostic features of CC.
Histological specimens were fixed with formalin, embedded in paraffin, cut into 3 µm sections, and stained with haematoxylin and eosin (H&E) for histological examination. Images were taken using OLYMPUS IX71 light microscope (x20 magnification) equipped with Q IMAGING EXI aqua camera at (1392 x 1040 pix.) resolution and 24-bit pixel encoding. Registered image pixel values were normalized in RGB colour space by histogram alignment using empty tissue-less areas using an algorithm described previously (4). Superpixel technique using Simple Linear Iterative Clustering algorithm (5) was used for initial segmentation of the images. All 1000 superpixels defined in each image were annotated by the expert, indicating ones containing thickened subepithelial collagen layer as the sought class among the others containing the rest of the tissue indicated as normal class. The feed – forward neural network (implemented in MatLab environment) was trained to classify superpixels using their normalized histogram bin-counts of the pixel values as a feature. Due to significant inequality in the data set, where the number of sought class superpixels was significantly smaller than the number of the remaining ones, the training set was formed by equalising it to the lowest class case’s value (18761). Only randomly selected cases of the bigger class were included in the training set.

Results

The proposed algorithm was tested on images from 5 treatment-naive patients with newly diagnosed CC. Patients' histological specimens were rated by an expert pathologist and 50 images were chosen (with changes characteristic of CC and without). The classification training process with extracted data set took 0.13 seconds on personal computer with an AMD Ryzen Threadripper 3970X 32-Core, 3.70 GHz processor and 128GB of RAM memory, epochs for training was set to 30 (after tests the model was not improving after 30 epochs) and data shuffling was set to every-epoch. The algorithm showed 0.807 accuracy, 0.801 sensitivity and 0.813 specificity.

Conclusion

The shown ability of deep learning algorithm to classify histology image segments can assist the diagnostic process of CC emphasizing thickened subepithelial collagen layer – the essential diagnostic feature.

References

1. Miehlke S, Guagnozzi D, Zabana Y, Tontini GE, Fiehn AMK, Wildt S, et al. European guidelines on microscopic colitis: United European Gastroenterology (UEG) and European Microscopic Colitis Group (EMCG) statements and recommendations. United European Gastroenterol J. 2020;
2. Verhaegh BPM, Münch A, Guagnozzi D, Wildt S, Cebula W, Diac AR, et al. Course of Disease in Patients with Microscopic Colitis: A European Prospective Incident Cohort Study. J Crohns Colitis. 2021;15(7):1174–83.
3. Weimers P, Ankersen DV, Lophaven S, Bonderup OK, Münch A, Løkkegaard ECL, et al. Incidence and Prevalence of Microscopic Colitis between 2001 and 2016: A Danish Nationwide Cohort Study. J Crohns Colitis. 2021;14(12):1717–23.
4. Petrolis R., Čižas P., Borutaitė V., Kriščiukaitis A. Method of fluorescence imaging for evaluation of membrane potential in cultured neurons using transmembrane voltage sensitive dye. Biomedical engineering 2011: Proceedings of International Conference. 14:16-19, 2011.

5. Achanta R, Shaji A, Smith K, Lucchi A, Fua P, Susstrunk S. SLIC Superpixels Compared to State-of-the-art Superpixel Methods. IEEE Transactions on Pattern Analysis and Machine Intelligence, Volume 34, Issue 11, pp. 2274-2282, May 2012

Introduction

Inflammatory bowel disease (IBD) is a growing cause for concern and often missed or not thought of among pediatric population in developing economies. It is reported that about 25% of IBDs present before the age of 20.
Growing plethora of investigations have not been able to replace the role of direct visualisation of intestinal mucosa in various colorectal issues. Macroscopic findings may or may not help in clinching the diagnosis of IBD, hence “Biopsy” remains the Elixir of diagnosis. In this article, we review and attempt to correlate colonoscopic(macroscopy) and histological (microscopy) findings of colonoscopies in pediatric population, done over a period of 1 year.

Aims & Methods

Aim and objectives: To compare macroscopic findings versus histopathology findings of colonoscopies in pediatric population in suspected IBD.
To study the correlation of macroscopic findings with histopathologic findings of colonoscopies in pediatric population and to assess the frequency and pattern of microscopic impressions of colonoscopies in our cohort.
Material and methods: A prospective observational study carried out in a tertiary referral centre in children who underwent colonoscopies, aged 1 month to 17 years over a period of 12 months.
All children whose parents consented were included in the study. Inclusion and Exclusion criteria were formulated. Informed consent was obtained from the parents. Clinical details, colonoscopy findings and histopathology reports were. A total of 135 cases were enrolled during our study period. Results were collated using Microsoft Excel ™.
© Ethical clearance was obtained from the institutional ethical committee.

Results

We found that the diagnosis of IBD was much more specific than expected with good sensitivity when data was matched between Macroscopy and Microscopy

Conclusion

• It is our standard practice to do colonoscopic biopsies from 7 areas (terminal ileum, cecum, ascending colon, transverse colon, descending colon, sigmoid colon, rectum) of the colon to exclude microscopic colitis which may be missed by the endoscopist or marked as ‘normal’.
• Microscopic findings are considered as ‘Gold standard’ in the diagnosis of IBD and we envisage that it will remain the gold standard in the many next decades to come
• Our data of sensitivity and sensitivity of the microscopic findings inclined the relevance of colonic mucosal biopsies in children with a normal-appearing mucosa and also the need to analyse every segment of the colon to diagnose IBD that may masquerade as “normal” in children which will add burden to the family, society and health care system and more importantly to the child’s quality of life.

References

1. Manfredi, Michael A et al. “Good agreement between endoscopic findings and biopsy reports supports limited tissue sampling during pediatric colonoscopy.” Journal of pediatric gastroenterology and nutrition vol. 58,6 (2014): 773-8.
2. Altamimi, Eyad & Odeh, Yousef & Al-Quraan, Tuka & Mohamed, Elmi & Rawabdeh, Naif. (2022). Diagnostic and therapeutic outcomes of pediatric colonoscopies in Jordanian children. Journal of Pediatric and Neonatal Individualized Medicine. 11.

Introduction

In a previous case study, we reported the use of endoscopic band ligation for weight loss (1). Based on this, we performed the same procedure on 13 female cases.

Aims & Methods

This trial aimed to assess the efficacy and safety of endoscopic band ligation for weight loss among 13 female cases with initial body weight (kg) mean ± SD of 104.769 ± 17.316 (80–145), BMI mean ± SD of 40.4315 ± 4.9145 and a mean excess weight (kg) of 40.0769 ± 14.3669, Table 1.
For the endoscopy, the patients were sedated with propofol, and oxygen was used for endoscopic air insufflation. The ligatures were applied in the gastric body, starting distally; five parallel rows were created with 20–30 bands, with the last one placed in the proximal body. The entire procedure lasted 20–30 min.

Results

No immediate complications occurred during the endoscopy. After the procedure, the patients remained well and were discharged within 2–3 h. For the first three days, most complained of nausea, vomiting, and epigastric pain, and one patient experienced mild hematemesis. All complications were controlled with medications (pantoprazole 40 mg twice daily for the 1st month, plus antiemetics and antispasmodics as required).
The patients consumed a pureed diet for 2 weeks, followed by a soft diet for another 2 weeks. A follow -up endoscopy after 1 month revealed nicely healed ulcer scars in the gastric body, causing marginal narrowing of the lumen.
The patients’ weight loss (kg) was mean ± SD 96.6154 ± 16.8004, corresponding to 22.336% excess weight loss and 7.8752% total weight loss after 1 month, Table 2.

Conclusion

Endoscopic band ligation for weight loss is a new procedure that may help in the management of obesity. The procedure was safe and cost-effective; however, more studies are needed to assess the effectiveness and safety of band ligations in the management of obesity.

References

1. Abeid Mohamed, Kaddah Tarek. Endoscopic band ligation for weight loss. Endoscopy 2021; 53: E287–E288.

Introduction

The success rate of endoscopic retrograde cholangiopancreatography (ERCP) is suboptimal in patients with complex surgically altered anatomy (e.g. Roux-en-Y anastomosis, pancreaticoduodenectomy) due to difficulty in advancement of scope to the target site and selective biliopancreatic duct cannulation. Although balloon-assisted enteroscopy can achieve a higher rate of intubation, its clinical application is limited by its small working channel and few compatible accessories.

Aims & Methods

We aimed to explore the feasibility and effectiveness of a novel endoscopic approach in patients with complex surgically altered anatomy.
This is a retrospective study of patients who underwent ERCP with complex surgically altered anatomy at our center with an annual ERCP volume of approximately 3000, between January 2018 and November 2022. The endoscopic procedures were performed by three senior endoscopists who had ERCP experience for at least 5 years. Long colonoscopy (measuring 168cm)-assisted ERCP was adopted as a first-line intervention, and selective biliopancreatic duct cannulation was performed after the target site (native papilla or the surgical anastomosis) was reached. For patients with failed cannulation, a plastic guide tube measuring 250 cm was inserted via the working channel of the colonoscope and its distal end was placed near the target site. The colonoscope was then withdrawn while the guide tube was left in-situ. By following the guide tube, a conventional side-viewing duodenoscope was cautiously advanced to the target site and biliopancreatic duct cannulation re-attempted.

Results

A total of 58 patients were recruited (mean age:56.7 years [standard deviation [SD]:14.4; male:36 [62.1%]]. The reconstruction methods were as follows – Roux-en-Y hepaticojejunostomy:32 (55.2%), Billroth-II gastrectomy with Braun anastomosis:11 (19.0%), pancreaticoduodenectomy:10 (17.2%) and Roux-en Y gastrectomy:5 (8.6%). Common bile duct stone was the most common indication for ERCP (n=30; 51.7%), followed by bilioenteric anastomotic stenosis (n=15; 25.9%), pancreaticojejunal anastomotic stenosis (n=7; 12.1%) and chronic pancreatitis (n=6; 10.3%). 55 (94.8%) of 58 had successful intubation by long colonoscope with a mean procedure time of 57.7minutes (SD:23.4). The mean time to reach target site was 19.1minutes (SD:9.0). The target site could not be identified in two patients and intestinal perforation occurred during endoscopic intubation in one patient. Among those with successful endoscopic intubation, biliopancreatic duct cannulation was achieved in 35 (63.6%) patients. For the remaining 20 patients with initial failure of biliopancreatic duct cannulation, intubation rate by duodenoscope was 100% by tracing the guide tube to target site. The success rate of biliopancreatic duct cannulation by duodenoscope was 85% (17/20) with a mean procedure time of 83.5 minutes (SD:21.1). The mean time to reach target site was 17.0minutes (SD:6.1). Notably, 90% (18/20) had either native papilla or pancreaticojejunostomy, in which selective biliopancreatic duct cannulation is known to be technically difficult with any type of forward-viewing scope due to unfavorable cannulation trajectory. For those with failed cannulation, two had anatomical stricture and one had impacted pancreatic stone.

Conclusion

ERCP by conventional duodenoscope with colonoscopy-assisted pre-placement of guide tube is a feasible, effective and safe alternative for patients with complex surgically altered anatomy in experienced endoscopists.