Introduction

Endoscopic resection for gastric subepithelialtumors(SETs) originated from the muscularispropria (GSET-PM) has offered less invasive alternatives to surgical resection.

Aims & Methods

The aims of this study were to compare endoscopic subtumoraldissection(ESD) with surgical resection for the removal of GSET-PM. This study involved 17 patients with GSET-PM removed by ESD and 76 patients who underwent curative surgical resection. ESD was attempted in GSET-PM with well marginated tumors which was below 5cm and showed an endoluminal growth pattern according to endoscopic ultrasound(EUS) finding.

Results

ESD group were more likely to have upper portion(10/17, 58.8%) and surgery group were more likely to have mid portion(41/76, 53.8%)(p=0.039). ESD group were smaller median tumor size (25.6 mm vs 35.9 mm, p=0.037) and higher endoluminal ratio (58.5±9.1 % vs 45.8±15.4 %, p=0.002). ESD group were mostly to have Yamada type III (10/17, 58.8%) and surgery group were mostly Yamada type I (52/76, 68.4%)(p< 0.001). Complete resection by ESD was lower than by surgical resection (82.4% vs 100%, p< 0.001). In ESD group, 3 performed surgical resection after ESD (1 incompletely resection and 2 uncontrolled bleeding) and 1 showed perforation was completely resected with endoscopic closure. In surgery group, complications occurred in 6 patients (1 leakage, 1 stricture, 1 hernia and bowel obstruction, 1 wound infection and 2 worsened general condition after surgery). Although surgery group were lower in complication rate than ESD group (p=0.006), severity of complications were higher in the surgery group and there were no mortalities in the ESD group compared with 2 in the surgery group. There was no statistical difference of recurrence and the follow-up period between two group.

Conclusion

ESD can be one of good options for the resection of endoluminal GSET-PM and could be replace treatment by surgical resection in Yamada type III with a high endoluminal ratio.

Introduction

Optimal timing of endoscopy in patients with acute variceal bleeding (AVB) remains unclear. Studies in patients with peptic ulcer bleeding (PUB) have indicated that urgent endoscopy <6 hours from presentation may be associated with worsened patient outcome. We aimed to analyse the association between timing of endoscopy and mortality in AVB.

Aims & Methods

Prospective multicenter cohort study based on data from the 2022UK Audit on Acute upper gastrointestinal bleeding. The association between timing of endoscopy and in-hospital mortality was evaluated using logistic regression analyses with adjustment for differences in patients’ characteristics and severity of bleeding.

Results

We included 401 AVB patients. Mean age was 58 years, 65% were males, 75% had known cirrhosis at time of presentation, mean Child-Pugh score was 8.2, 31% had other comorbidities, 13% had ongoing bleeding at time of endoscopy, 78% were treated with terlipressin, 75% were treated with antibiotics, and 12.6% died during hospital admission. Mortality rates were 22%, 17%, 11%, and 11% for patients undergoing endoscopy in the periods <6, <12, 6-24 and >24 hours from presentation. Patients undergoing endoscopy < 6 hours had lower blood pressure, higher heart rate, lower haemoglobin, and higher peak-lactate levels than patients undergoing later endoscopy (see table). However, even haemodynamically stable patients with systolic blood pressure above 100mmHg had high mortality rates (16%) when performing urgent endoscopy < 6 hours. When adjusting for differences in patients’ characteristics, and severity of bleeding, we did not find any association between timing of endoscopy and mortality (Odds ratio (95% confidence interval): 1.01 (0.99-1.03); p=0.17).

Table: Patient characteristics in relation to time of endoscopy (n=401)

Conclusion

AVB is associated with significant mortality, in particular in patients undergoing urgent endoscopy <6 hours from presentation, which may be explained by more severe bleeding. When taking differences in patients characteristics and severity of bleeding into consideration, endoscopy within 6-12 hours appears to be associated with similar outcomes to endoscopy undertaken 6-24 hours from presentation, despite less time to patient optimization before endoscopy. Thus, the association between timing of endoscopy and outcome may differ between patients with AVB and patients with PUB.

Disclosure

No conflicts of interest.

Introduction

Eosinophilic oesophagitis (EoE) is a chronic, T-helper type 2 immune-mediated oesophageal disease, characterized by symptoms of oesophageal dysfunction and eosinophil-predominant inflammation. In adults, the main clinical presentation associated with EoE is dysphagia and/or food impaction (FI); gastroesophageal reflux-like (GER-like) symptoms are less common but may also be the presenting symptoms.

Aims & Methods

We aimed to assess and compare the clinical, endoscopic, and histological characteristics of adult EoE patients presenting with FI or with no FI (NFI).
A single-center cross-sectional study was conducted on consecutive adult EoE patients (April 2023-April 2024). Based on presenting symptoms, patients were grouped into: I) FI patients, diagnosed following an emergency endoscopy, and II) NFI patients, diagnosed due to the presence of dysphagia or GER-like symptoms (i.e. heartburn, regurgitation, retrosternal-pain) in an outpatient setting. Symptoms were evaluated according to a structured questionnaire. All patients underwent gastroscopy with at least 6 biopsies from distal and medium/proximal oesophageal third. EoE was diagnosed if eosinophils were ≥ 15/high power field, in any biopsy specimen.
The main features were compared between FI and NFI patients by Chi-square and/or Student’s t test for dicotomic or continuous variables.

Results

Thirty-one EoE patients were included [males 74.2%, median-age 34 (19-57) years, BMI ≥ 25 Kg/ m² 61.3%]. FI patients (13; 41.9%) [males 76.9%, median-age 39 (20-57) years] and NFI patients (18; 58.1%) [males 72.2%, median-age 33 (19-57) years] did not differ in terms of age, gender, and BMI (p=0.33, p=1.00, p=0.71, respectively). Moreover, no differences were observed in the occurrence of atopy and the use of proton pump inhibitors (before EoE diagnosis) between FI and NFI groups [30.1% vs 50% (p=0.46) and 46.1% vs 66.6% (p=0.29), respectively].
Before EoE diagnosis, dysphagia and heartburn were less frequently reported in FI patients compared to NFI patients [38.5% vs 83.3% (p=0.02) and 23.1% vs 72.2% (p=0.01)]. Furthermore, 84.6% of FI, compared to 5.5% of NFI patients, showed a diagnostic delay of more than 5 years (p<0.005). The mean EREFS score was significantly higher in FI patients than in NFI patients [5.3 ± 1.8 vs 3.3 ± 2.1 (p=0.005)]. According to the EREFS score, inflammatory (based on Edema, Exudates, and Furrows scores) and fibrostenotic (based on the Rings and Strictures scores) phenotypes were both higher in FI patients than in NFI patients [3.2 ± 1.3 vs 2.1 ± 1.7 (p=0.03) and 2.2 ± 0.8 vs 1.3 ± 0.8 (p=0.005), respectively].

Conclusion

EoE patients presenting with food impaction seem to be paucisymptomatic before the EoE diagnosis compared to those without food impaction. This may explain the delay of EoE diagnosis often requiring emergency gastroscopy.

Introduction

In Japan, more than ten years have passed since direct oral anticoagulants (DOACs) was released in 2011. The differences between DOACs and warfarin (VKA) have gradually become clearer, and many studies have been reported regarding the differences in gastrointestinal bleeding risk ^(1)(2)(3). However, there are few reports that examine the prevalence of gastric mucosal injury or ulcers rather than the risk of bleeding.

Aims & Methods

The aim of this study is to reveal the clinical features about patients with gastric ulcer taking anticoagulants (DOACs or VKA). This study is a retrospective cross-sectional study conducted in a single hospital. Data were extracted from the records of subjects who underwent upper gastrointestinal endoscopy at our department between April 2015 and December 2022. We focused on subjects who took anticoagulants (DOACs or VKA), and compared the prevalence of gastric ulcer between subjects taking DOAC and those taking VKA. Subjects taking anticoagulants were limited to those taking that anticoagulant as the only anti-thrombotic agents. This study was conducted separately for subjects taking antacids (P-CAB or PPI) and those not taking antacids (NO P-CAB, NO PPI and NO H2RA). Statistical analyses were performed by Fisher’s exact test.

Results

Of the 8,602 subjects analyzed, 522 subjects were taking anticoagulants, of which 103 were taking VKA (76 men, 27 women, mean age 73.1±12.0 years) and 297 were taking DOACs (205 men, 92 women, mean age 74.9±8.7 years). Among subjects taking DOACs, 33 subjects received Dabigatran, 93 received Edoxaban, 87 received Rivaroxaban, and 84 received Apixaban. The prevalence of gastric ulcer in subjects taking antacids was 6.7% (4/60) on VKA and 2.9% (5/170) on DOACs (p=0.24). The prevalence of gastric ulcer in subjects not taking antacids was 23.1% (9/39) on VKA and 5.4% (6/111) on DOACs (p=0.004).

Conclusion

Without concomitant use of antacids, subjects taking DOACs had a statistically significantly lower prevalence of gastric ulcers than those taking warfarin. These results suggest that DOACs are gentler on the gastric mucosa and user friendly than warfarin.

References

(1) Miller CS, et al. Clin Gastroenterol Hepatol. 15(11): 1674-1683, 2017
(2) Ray WA, et al. JAMA. 320(21): 2221-2230, 2018
(3) Ingason AB, et al. Ann Intern Med. 174(11): 1493-1502, 2021

Introduction

Persistent High-Risk Human Papillomavirus (HR-HPV) infection can lead to an anal high-grade squamous intraepithelial lesion (HSIL), the precursor lesion to anal squamous cell carcinoma (SCC). Anal cytology and HR-HPV testing are strategies used for anal SCC screening. Anal HR-HPV prevalence in HIV-negative MSM and in MSM living with HIV (MSM-HIV) is 41% and 74%, respectively. The use of Pre-Exposure Prophylaxis (PrEP) in HIV-negative MSM to prevent HIV contraction created a new Sexual Minority Group among MSM, i.e. MSM using PrEP (MSM-PrEP). The aim of this study was to determine the prevalence of anal HR-HPV infection and abnormal anal cytology in MSM-PrEP and MSM-HIV.

Aims & Methods

MSM-PrEP and MSM-HIV were enrolled in this mono-centric study during consultations at the S-clinic and the HIV-reference centre respectively. Patient characteristics, sexual behavior and demographics were collected using a questionnaire, completed on the day of the anal swab testing.

Results

We enrolled 150 MSM-PrEP and 152 MSM-HIV. Quality of anal swabs was sufficient in respectively 96.7% (n=145) and 96.1% (n=146). HR-HPV prevalence in MSM-PrEP was comparable with HR-HPV prevalence in MSM-HIV; respectively 74.5% (n=108) and 76.6% (n=111) tested positive for at least one HR-HPV (p=0.78). No significant difference in abnormal cytology was seen; 53.1% (n=77) of the MSM-PrEP and 57.2%(n=83) of MSM-HIV had either ASCUS, ASC-H, LSIL or HSIL (p=0.56).

Conclusion

The risk of HR-HPV infection and abnormal anal cytology in MSM-PrEP is comparable to that in MSM-HIV, both of which are higher than observed in HIV-negative MSM not using PrEP. This heightened prevalence of HPV in MSM-PrEP poses an increased risk for HSIL. Recent guidelines on anal screening from International Anal Neoplasia Society recommend screening for anal cancer in both MSM-HIV and HIV-negative MSM, reflecting respective anal cancer incidence rates of 70-100 per 100,000 person-years and 18-34 per 100,000 person-years. Our findings suggest that MSM-PrEP constitutes a distinct risk group for anal SCC positioned between MSM-HIV and HIV-negative MSM not using PrEP.

References

Gaisa M, Gypsyamber D et al. Epidemiology of anal human papillomavirus infection and high-grade squamous intraepithelial lesions in 29 900 men according to HIV status, sexuality, and age: a collaborative pooled analysis of 64 studies. Lancet HIV. 2021;8(9):531-43.
Machalek D, Poynten M, Jin F et al. Anal human papillomavirus infection and associated neoplastic lesions in men who have sex with men: a systematic review and meta-analysis. Lancet Oncol. 2012;13(5):487-500.
Stier E, Clarke M, Deshmukh A et al. International Anal Neoplasia Society's consensus guidelines for anal cancer screening.Int.J.Cancer.2024;154:1694-1702.

Introduction

The optimal timing of endoscopy in acute upper gastrointestinal bleeding (AUGIB) management remains debated. We assessed time to endoscopy's impact on rebleeding and mortality based on patient characteristics and pre-endoscopic factors.

Aims & Methods

Data from 3,001 patients with AUGIB undergoing endoscopy within 48 hrs of referral from the prospective multicentre UK 2022 audit were analysed. Patients were categorised into 0-12 hrs, 12-24 hrs, and 24-48 hrs groups based on the time to endoscopy from referral. Regression analyses, adjusting for age, admission status (inpatient vs new admission), vital signs, symptoms, comorbidities, laboratory parameters, red blood cell transfusion, and pre-endoscopic management, assessed the association between endoscopy timing and rebleeding and mortality.

Results

Patients undergoing endoscopy within 0-12 hrs were younger, more likely to be haemodynamically unstable, and had a higher median Glasgow Blatchford Score (GBS) compared to those undergoing endoscopy in the 12-24 and 24-48 hrs groups. Despite a higher proportion receiving endotherapy (41% for the 0-12 hrs group, 28% for the 12-24 hrs group, and 17% for the 24-48 hrs group; p<0.001), the 0-12 hrs group had the highest rates of rebleeding (16%) and mortality (10%), compared to 9% rebleeding and 6% mortality in the 12-24 hrs group, and 7% rebleeding and 5% mortality in the 24-48 hrs group (p<0.001). The median length of stay was longer for the 0-12 hrs and the 24-48 hrs groups at 5 days, compared to 4 days in the 12-24 hrs group (p < 0.001). (see table)

Regression analysis indicated that, compared to the 12–24-hrs group, the 0–12 hrs group had higher odds of rebleeding (OR 1.91, 95% CI 1.38-2.69, p < 0.001), after adjusting for confounding variables. However, the 24–48 hrs group exhibited comparable odds of rebleeding (OR 0.93, 95% CI 0.60-1.45, p < 0.001) compared to the 12–24-hrs group. Regression analysis for mortality showed the 0-12 hrs group had higher odds of mortality compared to the 12-24 hrs group (OR 1.59, 95% CI 1.09-2.34, p = 0.001), while the 24-48 hrs group had similar odds of death (OR 0.74, 95% CI 0.43-1.23, p = 0.001).

Conclusion

The findings suggest a complex relationship between the timing of endoscopy and clinical outcomes in patients with AUGIB. Earlier endoscopy (0-12 hrs) may be associated with a higher risk of rebleeding, mortality and resource utilisation, while later endoscopy (24-48 hrs) may not be associated with increased adverse outcomes, but may lead to a longer hospital stay. Despite the initial severity of illness, early endoscopy may not translate to improved patient outcomes in AUGIB management. These results highlight the need for individualised management when determining the optimal timing of endoscopy in AUGIB.

Introduction

Persistent high-risk Human Papillomavirus (HR-HPV) infection can lead to an anal high-grade squamous intraepithelial lesion (HSIL), the precursor lesion to anal squamous cell carcinoma (SCC).
HR-HPV prevalence is higher in men who have sex with men living with HIV (MSMLWH) than in HIV-negative MSM, respectively 74% and 37-41% (1,2). The use of Pre-Exposure Prophylaxis (PrEP) in HIV-negative MSM to prevent HIV contraction created a new Sexual Minority Group among MSM, i.e. MSM using PrEP. The aim of this study was to determine the prevalence of anal HR-HPV infection and abnormal anal cytohistology in MSM using PrEP and MSMLWH. Preliminary data are reported here and final results are expected in coming months.

Aims & Methods

MSM using PrEP and MSMLWH were enrolled in this mono-centric study during consultations at the S-clinic and the HIV-reference centre respectively. Patient characteristics, sexual behavior and demographics were collected using a questionnaire, completed on the day of the anal swab testing. Patients with HR-HPV infection, abnormal cytology or both were subsequently sent for High Resolution Anoscopy (HRA).

Results

At present, we enrolled 150 MSM using PrEP and 107 MSMLWH. Quality of anal swabs was sufficient in respectively 95% (n=143) and 81% (n=87). HR-HPV prevalence in MSM using PrEP was comparable with HR-HPV prevalence in MSMLWH; respectively 74% (n=106) and 75% (n=65) tested positive for at least one HR-HPV (p=1.000). No significant difference in abnormal cytology was seen; 53% (n=76) of MSM using PrEP and 58% (n=51) of MSMLWH had either ASC-US, ASC-H, LSIL or HSIL (p=0.6). Until today, 58 MSM using PrEP and 31 MSMLWH underwent HRA. Biopsies were performed in 43 MSM using PrEP and 25 MSMLWH. Preliminary results on histology of lesions show presence of anal HSIL in 19% (n=11) and 32% (n=10) respectively (p= 0.706).

Conclusion

MSM using PrEP have a similar risk of HR-HPV infection and abnormal anal cytohistology as MSMLWH, which is higher than what has been reported in HIV-negative MSM not using PrEP (1). ANCHOR showed that treating anal HSIL reduces the incidence of anal SCC in people living with HIV (3), but the risk of progression to anal cancer and thus the need for screening and treatment is to be investigated in this immunocompetent population of MSM using PrEP.

References

1. Wei F, Gaisa M, Gypsyamber D et al. Epidemiology of anal human papillomavirus infection and high-grade squamous intraepithelial lesions in 29 900 men according to HIV status, sexuality, and age: a collaborative pooled analysis of 64 studies. Lancet HIV. 2021;8(9):531-43.
2. Machalek D, Poynten M, Jin F et al. Anal human papillomavirus infection and associated neoplastic lesions in men who have sex with men: a systematic review and meta-analysis. Lancet Oncol. 2012;13(5):487-500.
3. Palefsky J, Lee J, Jay N et al. Treatment of Anal High-Grade Squamous Intraepithelial Lesions to Prevent Anal Cancer. N Engl J Med. 202;386(24):2273-82.