Clinical Case Summary

A middle-aged man underwent screening colonoscopy during which a diminutive (3–4 mm) polyp was removed by cold snare polypectomy. The procedure was uneventful. Within hours, he developed painless scrotal swelling. Examination revealed subcutaneous emphysema confined to the scrotum (scrotal crepitus) with a soft, non-tender abdomen. He remained afebrile with stable vital signs. Abdominal computed tomography (CT) demonstrated retroperitoneal free air tracking into the scrotum (pneumoscrotum) with no intraperitoneal free air or fluid. Despite the absence of peritoneal signs, the atypical location of free air prompted surgical consultation. An exploratory laparotomy was performed. Intraoperatively, no colonic perforation or contamination was identified, including at the polypectomy site. The air leak was presumed to stem from a sealed microperforation or mucosal defect that allowed retroperitoneal air dissection. The patient had an uneventful recovery and was discharged on postoperative day five. Pneumoscrotum is a rare but recognized complication of colonoscopy, usually resulting from retroperitoneal air dissection without overt perforation (1–3). Most reported cases have been managed conservatively; however, when air dissects into atypical anatomical compartments or if clinical uncertainty exists, surgical exploration may be warranted to exclude a full-thickness injury (2,3). This case highlights the need for individualized management based on clinical and radiological findings, and underscores a rare complication of a routine colonoscopic polypectomy.

References

1) Singh S, Thakur M. Pneumoscrotum after colonoscopy. Can J Gastroenterol. 2008;22(4):411–413.
— This case report describes an instance of pneumoscrotum following colonoscopic polypectomy, managed conservatively. It highlights air dissection from retroperitoneum into the scrotum and notes the rarity of the condition.

2) Graepler F, Lauer UM, Horger MS, et al. Pneumoscrotum after colonoscopic polypectomy. Endoscopy.2007;39(Suppl 1):E90.
— A rare case of post-polypectomy pneumoscrotum requiring laparotomy. No perforation was found intraoperatively, underscoring that extensive air can dissect without overt bowel rupture.

3) Fu KI, Sano Y, Kato S, et al. Pneumoscrotum: a rare manifestation of perforation associated with therapeutic colonoscopy. World J Gastroenterol. 2005;11(32):5061–5063.
— This article presents pneumoscrotum as a clinical manifestation of colonic microperforation and describes the potential retroperitoneal air pathway into the scrotum.

Clinical Case Summary

Introduction: Aortoesophageal fistula (AEF) is a rare but fatal cause of upper gastrointestinal bleeding. The disease progression is often rapidly if not promptly recognized.
The most common etiologies include thoracic aortic aneurysm (TAA) and prior aortic surgery. Early diagnosis remain challenge due to nonspecific symptoms. This case series highlights endoscopic features of AEF and the critical role of endoscopists in early detection.
Case present: We report three elderly patients (aged 76–82) who presented to the emergency department with massive hematemesis. One had a history of type B aortic dissection post thoracic endovascular aortic repair (TEVAR) ; the others had no known thoracic disease. None reported mid-thoracic pain. Laboratory data showed hemoglobin 5.1 to 6.2 g/dL without coagulopathy. Esophagogastroscopy (EGD) was performed within 1 hour in two patients, and at 9 hours in the third. EGD showed consistent findings in three cases: a subepithelial bulging mass with central blood clot adherent to the left quadrant (6–9 o’clock) of the mid-esophagus. CT confirmed AEF secondary to ruptured TAA in two patients. Unfortunately, one patient collapsed suddenly in the ED; the others underwent emergent surgery but died within 1 and 21 days postoperatively.(esophagectomy +/- TEVAR).
Discussion: Chiari’s triad (mid-thoracic pain, sentinel bleeding, fatal hematemesis) is classically associated with AEF but was absent in half patients. In our report, EGD can be a most timely and specific modality to early diagnosis of AEF, especially in patients without clear prior aortic disease. The typical endoscopic feature : bulging submucosal mass with central blood adherent clot may serve as a diagnostic clue. And the “hot-zone” of the AEF in EGD was located at left quadrant (six to nine o’clock) of mid esophagus .
Conclusion: Early recognition of typical characteristic and “hot zone” of AEF on EGD may improve timely diagnosis of AEF and guide life-saving interventions.

References

1. Bergqvist D. Arterioenteric fistula. Review of a vascular emergency. Acta Chir Scand 1987;153:81–6.
2. Hollander JE, Quick G. Aortoesophageal fistula: a comprehensive review of the liter- ature. Am J Med 1991;91:279–87.
3. Mortensen A, Hansen NF, Schiodt OM. Fatal aortoesophageal fistula caused by but- ton battery ingestion in a 1-year-old child. Am J Emerg Med 2010;28(984):e5-6.
4. Takeno S, Ishii H, Nanashima A, Nakamura K. Aortoesophageal fistula: review of trends in the last decade. Surg Today. 2020 Dec;50(12):1551-1559.

Introduction

This study aims to assess the impact of antithrombotic therapy on endoscopic findings in patients hospitalized for upper gastrointestinal bleeding.

Aims & Methods

We carried out a prospective, single-center cross-sectional study including 332 patients between June 2020 and February 2025. Patients were classified as antithrombotic (AT) users if they were receiving antiplatelet agents (such as low-dose aspirin or thienopyridines) and/or anticoagulants (including vitamin K antagonists, direct oral anticoagulants, or heparin).

Results

The mean age of the study population was 59 ± 16.7 years, with a marked male predominance (77.1%). Among them, 63 patients (19%) were receiving antithrombotic (AT) therapy—41 on antiplatelet agents and 39 on anticoagulants. Patients in the AT group were significantly older (68 vs. 57 years; p < 0.001) and had a higher burden of comorbidities (75.8% vs. 16.7%; p < 0.001). However, there were no significant differences between the AT and non-AT groups regarding the presence of active bleeding at endoscopy (12.7% vs. 16.8%; p = 0.425) or the need for endoscopic hemostasis (7.9% vs. 16%; p = 0.1).
In multivariate analysis, after adjustment for age, sex, comorbidities, active bleeding, and AT use, only the presence of active bleeding was independently associated with the need for endoscopic hemostasis. Specifically, active bleeding at endoscopy increased the odds of requiring hemostasis by 26-fold (OR: 26, 95% CI: 12.9–62.15; p < 0.001), whereas AT therapy was not an independent predictor (OR: 0.386, 95% CI: 0.105–1.42; p = 0.154).

Conclusion

In older patients receiving antithrombotic therapy and admitted for upper gastrointestinal bleeding, the risk of active bleeding during endoscopy and the need for endoscopic hemostasis do not appear to be increased.

Introduction

Gastrointestinal (GI) endoscopy requires not only technical skills but also strong non-technical abilities like communication, teamwork, and decision-making. Traditional training is often individualized, with little focus on interdisciplinary collaboration. Role Swapping (RS) — where physicians and nurses exchange tasks during simulated procedures — may enhance teamwork and mutual understanding.

Aims & Methods

A prospective pilot study was conducted involving 22 participants (10 endoscopists, 12 nurses) using in-silico colonoscopy simulators. The training included a pre-simulation skills assessment, theoretical onsite classes, randomized role-swapping simulation sessions, and a post-simulation evaluation after two weeks. Technical skills, non-technical skills (assessed via NOTSS and SPLINTS frameworks), and satisfaction were evaluated using validated questionnaires. Wilcoxon tests compared pre- and post-training scores.

Results

RS in simulated GI endoscopy training significantly enhanced both technical and non-technical competencies among participants. Post-training assessments using validated tools showed improvements across all evaluated domains. Situational awareness, decision-making, communication, teamwork, and leadership skills all exhibited statistically significant gains. Participants improved their ability to gather information (p=0.02), understand data (p=0.008), and anticipate future scenarios (p=0.002). Decision-making skills were notably enhanced, with better option consideration (p<0.001), more transparent communication of decisions (p=0.001), and greater adaptability to dynamic conditions (p<0.001). Communication improvements included more effective information exchange (p=0.007), better shared understanding (p=0.035), and increased team coordination (p=0.001). Leadership skills were also significantly strengthened, particularly in setting standards (p=0.002) and supporting teammates (p=0.012). Regarding technical skills, endoscopists reported substantial confidence improvements in tasks traditionally performed by nurses. Significant progress was observed in preparing endoscopic equipment (p=0.016), medication dilution (p=0.016), patient discharge procedures (p=0.014), instrument arrangement during interventional colonoscopies (p=0.026), and setup of patient monitoring systems (p=0.041). Confidence also increased in tasks initially rated as low-confidence, such as proper waste disposal after GI procedures (p=0.01). Nurses, conversely, enhanced their technical capabilities related to GI endoscopy performance. They showed greater proficiency in advancing the colonoscope (p=0.004), reducing loops (p=0.007), navigating angled turns (p=0.007), executing ancillary maneuvers (p=0.038), and conducting thorough mucosal inspections during withdrawal (p=0.036). Improvements were also seen in colonoscope insertion (p=0.026), understanding of colonoscopy quality indicators (p=0.011), and lesion identification (p=0.046). Participant feedback revealed high satisfaction with the RS training experience. Participants appreciated the opportunity to engage in cross-disciplinary tasks, reporting that the simulation increased their mutual respect, role awareness, and confidence in collaborative practices.

Conclusion

Role swapping during simulated GI endoscopy training enhanced both technical and non-technical skills and fostered better collaboration between nurses and physicians. This innovative educational approach shows potential to improve clinical practice quality and patient safety.

References

1. Hedges AR, Johnson HJ, Kobulinsky LR, et al. Effects of Cross-Training on Medical Teams’ Teamwork and Collaboration: Use of Simulation. Pharmacy (Basel) 2019; 7: 13.
2. de Laurentis C, Pirillo D, Di Cristofori A, et al. Boosting teamwork between scrub nurses and neurosurgeons: exploring the value of a role-played hands-on, cadaver-free simulation and systematic review of the literature. Front Surg 2024; 11: 1386887.

Introduction

Biliary obstruction caused by food is a little-known and reported long-term complication of endoscopic sphincterotomy (ES). This retrospective study aimed to characterize patients diagnosed with this condition between 2012 and 2025 and assess the outcomes of surgical therapy.

Aims & Methods

Patients were included when diagnosed with symptomatic duodenal reflux of food (DBR-F) following prior ES and who subsequently underwent hepaticojejunostomy with partial resection or ligation of the common bile duct. DBR-F was diagnosed by pathological examination of material extracted from the common bile duct during episodes of biliary obstruction. Data were assessed retrospectively using the hospital’s electronic patient record system. The long-term outcome and satisfaction with treatment were also evaluated using a questionnaire.

Results

We identified 12 patients (6 male; median age 60.9 years) who had previously undergone cholecystectomy and ES for gallstone disease and thereafter required frequent hospitalization and multiple ERCPs for stone or sludge removal with microscopic proof of DBR-F. All these patients presented with (episodic) abdominal pain; 9 had episodes of cholangitis, in 2 associated with liver abscesses. The median interval between ES and the first ERCP for symptoms of DBR-F was 2.2 years and ranged from 4 months to 22 years. The median interval between the first ERCP for DBR-F related symptoms and diagnosis, i.e. the diagnostic delay, was 3.3 (IQR 2.1-6.6) years. Conservative management, including antibiotics and ursodeoxycholic acid, and endoscopic treatment such as repeat sphincterotomy and biliary stenting were ineffective. The median number of ERCPs for DBR-F related symptoms/complications before surgery was 9.5 (IQR 7.3-10.0). Surgical treatment was associated with several complications, including insufficient ligation of the common bile duct requiring re-operation in 2 cases and stenosis of the hepatico-jejunostomy anastomosis requiring 3 sessions of balloon dilatation in 1 case. The median follow-up after surgery was 8.9 years. At last follow-up 90% of patients were asymptomatic and expressed a high level of satisfaction with surgical treatment.

Conclusion

This single-center series suggests that DBR-F is a long-term and serious complication of ES that must be more prevalent than is currently indicated by anecdotal literature. This diagnosis should be considered when patients present with recurrent ‘stones’ or ‘sludge’ after previous ES. In patients with recurrent symptomatic DBR-F surgical therapy is an effective option.

Introduction

Advances in therapeutic drug monitoring (TDM) have significantly improved the understanding of the relationship between anti-TNF-alpha drug concentrations and disease activity in patients with Crohn’s disease (CD). Early dose optimization of adalimumab (ADAL) and higher serum trough concentrations are associated with increased clinical, biochemical, and endoscopic remission in CD^1,2,3,4. This study aimed to evaluate whether early dose optimization of ADAL to a trough level >15 µg/mL improves clinical and biochemical remission rates at 12 weeks compared to standard dosing.

Aims & Methods

This study aimed to evaluate whether early dose optimization of ADAL to a trough level >15 µg/mL improves clinical and biochemical remission rates at 12 weeks compared to standard dosing. This was a randomized, multicenter, open-label trial evaluating TDM-guided ADAL dose optimization versus standard dosing in biologic-naïve and experienced patients with active CD. In the dose optimization arm , after standard induction doses at Weeks 0 (160 mg) and 2 (80 mg), patients with trough levels ≤15 µg/mL at week 4 received an additional 80 mg at Week 6 followed by 40 mg every week. Patients in the optimization arm who had trough levels >15 µg/mL at week 4 and all patients in the standard care arm remained on 40 mg every 2 weeks. The primary endpoint was a composite of clinical and biochemical remission at Week 12, defined as Harvey-Bradshaw Index (HBI) <5 and C-reactive protein (CRP) <5 mg/L or fecal calprotectin (FCal) <250 µg/g.

Results

A total of 77 patients were enrolled in the trial (39 in optimization arm vs 38 in standard care arm). At week 4, 15/39 patients in the intervention arm were eligible for dose optimization, with twelve going on to receive the accelerated regimen. At week 12, 6/12 (50%) of the optimized patients achieved an ADAL trough level >15 µg/mL. A numerically higher proportion of patients in the dose optimization arm achieved the primary endpoint compared to the standard care arm, however this difference was not statistically significant (17 (43.6%) vs 12 (31.6%), p = 0.394). In total, eleven patients in the optimization arm (28.2%) and seven patients in the standard care arm (18.4%) achieved an ADAL trough >15 µg/mL, with mean trough levels being numerically higher in the optimization group (18.1 vs 12.8 µg/mL, p = 0.160). ROC analysis of the predictive value of Week 12 trough levels on the primary outcome determined an optimal threshold level of 18.2 µg/mL (AUC 0.68, sensitivity 88.9%, specificity 39.3%). When analyzing the entire cohort, patients who achieved an ADAL trough >15 µg/mL (whether they were dose-optimized or not) at Weeks 8 or 12 were significantly more likely to achieve combined clinical and biochemical remission (19/27 patients (70.4%) vs 10/50 patients (20.0%), p < 0.001). Taken separately, both clinical and biochemical remission occurred more frequently in patients who achieved an ADAL trough >15 µg/mL (clinical: 22/27 (81.5%) vs 16/50 (32.0%), p <0.001; biochemical: 22/27 (81.5%) vs 14/50 (28.0%), p < 0.001). No difference in adverse effects was observed between trial arms. The major limitation of the trial was the small sample size and patient withdrawal due to the COVID 19 pandemic.

Conclusion

Although proactive dose optimization did not significantly increase remission rates compared to standard dosing, achieving an ADAL trough level >15 µg/mL at Week 8 or 12 was strongly associated with higher remission rates. These findings support early TDM-driven dose escalation and suggest that maintaining ADAL >15 µg/mL is a key target for achieving biochemical remission.

References

1. Little RD, Swaine A, Reynolds R, et al. Adalimumab Drug Levels at Secondary Loss of Response Do Not Predict Response to Dose-intensification in Crohn’s Disease: A Retrospective, International Multicenter Study. Inflamm Bowel Dis. 2024;30(10):1714-1723. doi:10.1093/ibd/izad248
2. Assa A, Matar M, Turner D, et al. Proactive Monitoring of Adalimumab Trough Concentration Associated With Increased Clinical Remission in Children With Crohn’s Disease Compared With Reactive Monitoring. Gastroenterology. 2019;157(4):985-996.e2. doi:10.1053/j.gastro.2019.06.003
3. Chaparro M, Guerra I, Iborra M, et al. 538 Correlation Between Adalimumab Serum Levels and Remission After the Induction Phase in Crohn’s Disease Patients. Gastroenterology. 2015;148(4):S-107-S-108. doi:10.1016/S0016-5085(15)30370-X
4. Kim MJ, Kim E, Kang B, Choe YH. Therapeutic Drug Monitoring of Adalimumab During Long‐term Follow‐up in Paediatric Patients With Crohn Disease. J Pediatr Gastroenterol Nutr. 2021;72(6):870-876. doi:10.1097/MPG.0000000000003070