Clinical Case Summary

Introduction: Patients with inflammatory bowel disease (IBD) are at risk of gastrointestinal neoplasm. The incidence of neuroendocrine tumors (NETs) in IBD is rare. We present a rare case of gastric NET in Crohn’s Disease (CD).
Case Report: A 42-year-old man with gastroesophageal reflux and hypertension was diagnosed with ileocolonic CD in 2014. CD management included no response to 5-aminosalicylate acid and azathioprine and adequate control with adalimumab. In 2020, he reported worsening non-bloody diarrhea and abdominal pain. C-reactive protein, albumin, liver enzymes and infectious workup were normal. Fecal calprotectin and small bowel imaging were unremarkable. Facial flushing was reported. 24-hour-urine 5-Hydroxyindoleacetic acid at 441 umol/d (0-43 umol/d), chromogranin A at 1410 ng/mL (≤76 ng/mL) and normal serum gastrin were noted. Abdominal computed tomography and octreotide scan were normal. Colonoscopy showed mild erythema in colon. Gastroscopy unveiled a clean-based malignant-looking ulcer at gastric fundus. Biopsy showed a well-differentiated NET-grade 1 (G1) (World Health Organization 2010). Oncology and general surgery were involved. As no metastases on imaging, a gastrectomy was planned, during which, liver metastases with peritoneal wall seeding were found; gastrectomy was cancelled. Liver nodules biopsy showed metastatic well-differentiated NET-G2 with stomach origin. Lanreotide was started; adalimumab was held. Hepatic transarterial embolization was done. Metastases progressed; cisplatin and etoposide were started. He was then switched to capecitabine and temozolomide for abnormal liver enzymes. CD flare was reported; vedolizumab was added. Despite management, his disease progressed. He passed away within two years.
Conclusion: Differentiating NETs from CD flare could be challenging as their symptoms overlap. Despite its rarity, considering NETs is essential when patients with IBD present with persistent diarrhea despite adequate disease control.

References

1. Gastroscopy: Moderate size, clean-based malignant appearing ulcer noted at gastric fundus.
2. Gastric biopsy Ki67
3. Gastric biopsy H&E stain high power
4. Liver H&E stain medium power
5. Liver biopsy Ki67 mild increased expression in NET

Disclosure

The authors have no conflict of interest to disclose.

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) is now the gold standard for treating biliopancreatic conditions. With growing operator experience and significant advancements in endoscope and instrument design, outcomes have markedly improved. However, the procedure still carries a risk of complications and is not always successful in clearing bile duct stones on the first attempt. In this context, our study aims to evaluate the complication rate of ERCP in the management of common bile duct stones and to explore what factors predict failure to clear these stones during the initial procedure.

Aims & Methods

The aim of this study is to evaluate the predictive factors associated with failure of complete biliary stone clearance during the initial endoscopic retrograde cholangiopancreatography (ERCP) procedure. This is a retrospective, descriptive, and analytical study conducted over a 20-year period, from September 2005 to September 2025. It includes all patients with bile duct stones who underwent ERCP with endoscopic sphincterotomy, followed by stone extraction using standard techniques such as an extraction balloon or Dormia basket.

Results

A total of 1,080 ERCP procedures were performed for the extraction of bile duct stones. The mean age of the patients was 58.9 ± 14.4 years, with a female predominance (59.5%). The average diameter of the common bile duct (CBD) was 13.4 ± 4.31 mm, and biliary strictures were observed in 6.3% of cases. The primary duct clearance rate was 75.1%, while supplementary techniques were required in 22.7% of cases.
On univariate analysis, several factors were significantly associated with failure of stone clearance using standard techniques: younger age (OR: 0.9; 95% CI: -0.03 to -0.01; p < 0.001), male gender (OR: 0.7; 95% CI: -0.5 to -0.02; p = 0.036), history of cholecystectomy (OR: 1.3; 95% CI: 0.02 to 0.6; p = 0.035), presence of cholangitis (OR: 0.4; 95% CI: -1.1 to -0.4; p < 0.001), CBD dilation >15 mm (OR: 0.8; 95% CI: -0.2 to 0.1; p < 0.001), biliary stricture (OR: 0.3; 95% CI: -1.7 to -0.7; p < 0.001), and presence of impacted and/or large stones (OR: 0.1; 95% CI: -2 to -1; p < 0.001).
Multivariate analysis identified four independent predictors of primary clearance failure: presence of cholangitis (OR: 1.9; 95% CI: 0.2 to 1; p = 0.001), impacted and/or large stones (OR: 2.5; 95% CI: 0.5 to 1.3; p < 0.001), CBD dilation >15 mm (OR: 0.88; 95% CI: -0.17 to -0.07; p < 0.001), and biliary stricture (OR: 2.9; 95% CI: 0.4 to 1.7; p = 0.002).
Following the application of supplementary techniques, the overall bile duct clearance rate increased to 92.4%.

Conclusion

In our study, the main predictors of failure to achieve primary common bile duct clearance were cholangitis, the presence of impacted and/or large stones, CBD dilation greater than 15 mm, and biliary strictures.

Introduction

Gallbladder cancer (GBC) has a poor prognosis due to its aggressive nature and limited treatment options. Although early diagnosis through imaging is critical, it remains difficult—particularly in cases of focal gallbladder wall thickening (FGWT), which can mimic benign conditions such as adenomyomatosis or chronic cholecystitis.

Aims & Methods

This study aimed to identify lesions that progressed to GBC (precancerous lesions of GBC; PLGBC) by evaluating prior imaging and to describe their clinical characteristics and outcomes. Patients diagnosed with GBC at Iwata City Hospital between 2014 and 2024 were retrospectively reviewed. Those who had prior imaging—defined as abdominal ultrasound (US), computed tomography (CT), or magnetic resonance imaging (MRI) performed more than three months before GBC diagnosis—were included for analysis. PLGBC was defined as a lesion identifiable on prior imaging but not diagnosed as GBC, and corresponding to the site of subsequently diagnosed GBC. Imaging features and clinical outcomes were compared between patients with and without PLGBCs.

Results

Among 140 patients diagnosed with GBC, 66 (47%) had prior imaging available for review and were included in the analysis. The median age at GBC diagnosis was 80 years (interquartile range [IQR]: 71–86), with 33 male patients (50%). The median interval between prior imaging and GBC diagnosis was 753 days (IQR: 404–1796). The modalities of prior imaging included CT only in 42 patients, US only in 7, MRI only in 1, US and CT in 6, CT and MRI in 6, US and MRI in 3, and all three modalities in 1 patient.
PLGBCs were identified in 32 patients (48%). Regarding lesion morphology, 28 patients presented with FGWT, 2 patients with diffuse gallbladder wall thickening (DGWT), and 2 patients with gallbladder polyps. Lesion locations were the neck in 5 patients, the body/fundus in 25 patients, and the entire gallbladder in 2 patients. Features such as intramural stones or Rokitansky–Aschoff sinuses (RAS) were observed in 15 patients, and gallstones in 7 patients.
No significant differences were found between patients with and without PLGBCs regarding resectability (36% vs. 35%, P = 1.00), radical resection rates (13% vs. 13%, P = 1.00), or survival from diagnosis (median: 640 vs. 791 days, P = 0.96). Six patients with PLGBC were diagnosed with GBC during observation of gallbladder lesions (median follow-up: 406 days, range: 350–552 days), and all underwent successful radical resection of GBC.

Conclusion

PLGBCs were identified in approximately half of the patients who had undergone imaging before their GBC diagnosis, with FGWT being the predominant imaging feature. Recognizing PLGBCs and ensuring appropriate follow-up may enable timely surgical intervention, offering a potential opportunity to improve outcomes in patients with GBC.

Introduction

In 2023, a total of 7,244 new cancer cases were recorded within the Mongolian population. Among these, stomach cancer represented 17.4%, while esophageal cancer accounted for 4.9%. Of all the cancer cases registered in 2023, 34.6% were diagnosed at an early stage, whereas 65.4% were identified at a late stage.The primary objective of endoscopy is to diagnose cancer at an early stage or at the point of cellular abnormalities. However, esophagogastroduodenoscopy (EGD) can cause significant discomfort for patients. In recent years, the use of sedated endoscopy has become increasingly common, which has had a notable impact on diagnostic outcomes.

Results & Findings

Method: The study was conducted retrospectively, involving 91 patients out of 218 who underwent cytology tests, selected from a total of 9,373 patients who visited the endoscopy department of Brilliant Hospital between January 2023 and December 2023. Among these, 91 individuals diagnosed with cellular abnormalities through tissue analysis underwent both sedated and non-sedated esophagoscopy. The cohort consisted of 50 women and 41 men. Regarding age distribution, one individual was aged 30-40 years, eight individuals were aged 41-50 years, 20 individuals were aged 51-60 years, 39 individuals were aged 61-70 years, and 23 individuals were aged 71 years or older.
Result: A total of 218 individuals underwent tissue analysis, of whom 91 were diagnosed with cellular abnormalities. Among these, 56 individuals were identified with sleep apnea, representing 61.5% (n=56) of the total cohort diagnosed with cellular abnormalities.

Summary & Discussion

The findings indicate that sedated endoscopy enhances diagnostic accuracy by improving patient comfort and enabling better tissue sampling. This is particularly important in Mongolia, where a high proportion of cancer cases are diagnosed at later stages, emphasizing the need for improved early detection. However, the study's retrospective design and single-center nature limit the generalizability of these findings. Further large-scale, prospective studies are necessary to confirm these results and investigate the role of sleep apnea in cytological abnormalities.

Conclusion

In conclusion, sedated endoscopy shows promise in improving diagnostic outcomes, and its use could be beneficial for early cancer detection.
This study demonstrates that sedation during esophageal and gastric endoscopy may significantly enhance the detection of cytological abnormalities. The association between sleep apnea and cellular changes also warrants further investigation. Given the high rate of late-stage cancer diagnosis in Mongolia, the implementation of sedated endoscopy could play a critical role in promoting early detection and improving clinical outcomes. Future multicenter, prospective studies are needed to validate these findings and guide policy on sedation practices in endoscopic procedures.

References

Endoscopy with sedation has been shown to increase the detection rate of early-stage cancer and benign abnormalities. A multi-center study involving 432,202 patients found that while the detection of benign upper gastrointestinal changes was similar between sedated and non-sedated groups, the detection rate of high-grade intraepithelial neoplasia (HGIN) and early cancers was higher in the sedated group. (pubmed.ncbi.nlm.nih.gov)
Endoscopy with sedation was more effective in detecting small-sized cancers. A study showed that the group receiving sedated esophagogastroduodenoscopy (EGD) had a 3-fold higher detection rate for small-sized cancers. (pubmed.ncbi.nlm.nih.gov)
Propofol-based sedation in endoscopy has been found to have higher diagnostic accuracy in detecting early-stage gastric cancers and benign abnormalities. A study in China demonstrated that endoscopy with propofol sedation had a significantly higher diagnostic accuracy in detecting early-stage gastric cancers and benign changes. (link.springer.com)