Introduction

Non-alcoholic fatty liver disease (NAFLD) is a common liver disease frequently associated with type 2 diabetes mellitus (T2DM). This systematic review and meta-analysis aims to quantify the prevalence of NAFLD and non-alcoholic steatohepatitis (NASH) among individuals with T2DM and evaluate the spectrum of liver fibrosis within this cohort.

Aims & Methods

Medline and Embase databases were searched to identify relevant studies published in English, from inception until 13th February 2023. Original articles reporting crude data necessary to calculate the prevalence of NAFLD or NASH in a T2DM population were included. NAFLD was diagnosed based on the criteria set by the American Association for The Study of Liver Diseases (AASLD) guidelines, while liver biopsies were required to identify NASH. Fibrosis was evaluated through non-invasive and invasive techniques.
T2DM was defined by glycohemoglobin ≥ 6.5%, fasting plasma glucose ≥ 7mmol/l, self-reported diabetes, or use of anti-diabetic medications.

Results

124 studies consisting of 1,689,498 individuals with T2DM were analysed. The prevalence of NAFLD in T2DM patients from population-based settings was 57.93% (95% CI: 49.55% to 65.88%). The pooled prevalence of NAFLD was 63.71% (95%CI: 59.94% to 67.32%), while the pooled prevalence of NASH was 31.46% (95%CI: 14.25% to 55.91%). Interestingly, the prevalence of NASH in T2DM patients was 49.55% (95% CI: 28.31% to 70.95%) in Western countries, while only 9.73% (95% CI: 1.84% to 38.28%) in Eastern countries. The frequency of clinically significant fibrosis (F2-4) was 19.82% (95%CI: 13.13% to 28.80%), and the frequency of advanced fibrosis (F3-4) was 14.08% (95%CI: 10.21% to 19.10%) among T2DM patients with NAFLD. This increased to 37.48% (95%CI: 22.16% to 55.80%) and 36.54% (95%CI: 19.05% to 58.49%) respectively among T2DM patients with NASH.

Conclusion

There is a high prevalence of NAFLD and NASH in individuals with T2DM, with nearly a fifth of T2DM individuals with NAFLD affected by liver fibrosis. Clinical management of patients with T2DM should include specific interventions aimed at the targeted prevention, diagnosis and management of NAFLD and its complications.

Introduction

Endoscopic submucosal dissection (ESD) is a valuable technique for the en-bloc resection of superficial neoplasms in the anal canal. However, its safety and efficacy in patients who have previously undergone transanal endoscopic surgery (TES) —such as transanal minimally invasive surgery (TAMIS) and transanal endoscopic microsurgery (TEM)—remain unclear.

Aims & Methods

To assess the safety and outcomes of ESD in the anal canal for patients with a history of TES compared to naïve patients.
A retrospective analysis was conducted at our tertiary center on 51 patients who underwent ESD in the anal canal between March 2010 and November 2024. Patients with a history of transanal endoscopic surgery were compared to those undergoing ESD as their primary treatment. Key parameters, including resection speed, perforation rates, coagrasper usage, inpatient status, late hemorrhage, and recurrence, were evaluated. Statistical analysis was performed to determine significant differences between groups.

Results

Histological examination confirmed the following cases: 3 adenocarcinomas (including 1 non-curative ESD), 15 adenomas with high-grade dysplasia, 11 adenomas with low-grade dysplasia, 2 sessile serrated lesions, 15 sessile serrated lesions with dysplasia, 2 high-grade intraepithelial lesions, 2 low-grade intraepithelial lesions.
The median resection velocity was slightly lower in patients with recurrence (16.01 mm²/min) compared to those without recurrence (25.56 mm²/min), though this difference did not reach statistical significance (p = 0.062). Perforation occurred in 9.62% of cases, with similar rates between groups (p = 0.58), suggesting that prior TEM does not significantly increase the risk of this complication. Late hemorrhage was observed in 7.84% of patients, again without a significant difference between groups (p = 0.29).
The only statistically significant finding was the smaller lesion size in patients with recurrence (1,162 mm² vs. 2,250 mm², p = 0.045). This is likely due to intensive post-TEM surveillance, which allowed for early detection of recurrence before lesions could grow larger. Other factors, including sex, age, use of coagrasper during the procedure, en-bloc resection, R0 status, and inpatient admission rates, showed no significant differences between groups.

Conclusion

ESD in the anal canal after prior TES appears to be a safe and feasible procedure, with outcomes statistically comparable to those in naïve patients. Although absolute numbers suggest differences, particularly in lesion size, these findings may be influenced by the small sample size. Larger studies are needed to confirm these results and further evaluate long-term efficacy.

Introduction

Gastrointestinal endoscopy is considered a key examination in the setting of anemia workup. However, the yield of esophagogastroduodenoscopy (EGD) and colonoscopy varies depending on the patient's presentation and the type of anemia.

Aims & Methods

The aim of our study was to evaluate the efficiency of EGD and colonoscopy in adult patients with anemia. We retrospectively analysed patients who underwent EGD or colonoscopy for anemia workup in our department between 2018 and 2024. Patients with symptoms suggestive of another cause of anemia were excluded. Additionally, patients who presented with gastrointestinal symptoms and patients with a history of gastrointestinal disease or surgery that could be related to the occurrence of the anemia were also excluded.

Results

A total of 564 patients were included in the study, with a mean age of 72 ±12.8 years. The majority of patients were women (52.8%). 84.9% of the patients underwent EGD, and 49.8% underwent colonoscopy. Overall, 34.8% of patients underwent both examinations. Furthermore, an additional 17.5% were not required to undergo the second examination due to a concrete cause of anemia being found in the initial examination, raising the percentage of patients who completed evaluation to 295 (52.3%). Most of the patients had iron deficiency anemia (IDA) (68.7%). 163 (28.9%) patients had an endoscopic finding that was considered the cause of anemia. EGD yielded significant findings in 119 (24.8%) patients, and colonoscopy in 46 (16.4%) patients. The most prevalent finding of colonoscopy was colon cancer (27 patients), while the most prevalent findings of EGD were peptic ulcer disease (37 patients), stomach cancer (24 patients), and severe atrophic gastritis (18 patients). There was a significant association between the type of anemia and the diagnostic yield of endoscopy, with endoscopic findings being significantly more prevalent in patients with IDA (36.1%) compared to patients without (13.8%) (p < 0.001).

Conclusion

Gastrointestinal endoscopy is the cornerstone examination in patients with unexplained IDA. Conversely, in patients with non-IDA anemia, while endoscopy retains significant diagnostic value, a simultaneous workup for other causes outside the gastrointestinal system is also indicated.

Introduction

Endoscopic submucosal dissection (ESD) is the technique of choice for treating early gastric cancer deemed to have very low risk of lymph node metastasis based on endoscopic evaluation. However, currently, up to 20% of ressected lesions do not meet curative criteria, underlining the importance of patient selection.

Aims & Methods

We aimed to evaluate predictive factors for non curative ressection. We conducted a retrospective cohort study including consecutive gastric epithelial lesions removed by ESD between January of 2005 and June of 2024. Incomplete ESD were excluded. Non curative resection was defined using the high-risk resection criteria from the European Society of Gastrointestinal Endoscopy guidelines. Univariate and multivariate analysis were used to identify predictive factors.

Results

From 990 ESD, 974 were included in the final analysis: median size of lesion 19mm (P25-P75: 15-25), presence of ulceration in 25 (2.8%), deep submucosal invasion in 74 (7.6%), en bloc resection in 944 (96.9%), R0 resection in 901 (92.5%) and non curative resection in 116 (11.9%). In this sample, the following independent predictive factors for non curative resection were identified: location on the superior third of the stomach [adjusted Odds Ratio (aOR) 2.275; IC95% 1.248-4.148], lesion size > 20mm (aOR 4.212; IC95% 2.618-6.775), depressed/ulcerated lesion (aOR 2.394; IC95% 1.328-4.315) or sessile/pedunculated lesion (aOR 4.186; IC95% 2.083-8.411), presence of high-grade dysplasia (aOR 4.372; IC95% 2.139-8.939) or carcinoma (aOR 12.484; IC95% 5.995-25.998) in previous biopsies.

Conclusion

Location, size and morphology of lesion, as well as previous biopsy results are predictive factors for non curative resection, and may assist in decision-making regarding treatment alocation of gastric superficial lesions.

References

Dinis-Ribeiro M, et al. Management of epithelial precancerous conditions and early neoplasia of the stomach (MAPS III): European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter and Microbiota Study Group (EHMSG) and European Society of Pathology (ESP) Guideline update 2025. Endoscopy, 2025 May;57(5):504-554. doi: 10.1055/a-2529-5025.
Vasconcelos AC, et al. Endoscopic Resection of Early Gastric Cancer and Pre-malignant Gastric Lesions. Cancers, 2023 Jun 7;15(12):3084. doi: 10.3390/cancers15123084.

Introduction

Functional bowel disorders are characterized by the presence of altered bowel habits with or without abdominal pain.¹ Irritable bowel syndrome (IBS) is diagnosed based on recurrent abdominal pain; however, distinctions in the clinical phenotypes of IBS subtypes and other functional bowel disorders (FBDs), such as functional diarrhea (FD) and functional constipation (FC), remain underexplored.^2,3

Aims & Methods

Aims: This study aimed to characterize the clinical presentation of IBS with predominant constipation (IBS-D) and IBS with predominant diarrhea (IBS-C), differentiating them from FD and FC, while recognizing the overlapping symptoms and the continuum between these conditions. Additionally, we examined the prevalence of psychological disorders and extra-intestinal comorbidities and identified potential mediators linking IBS to anxiety and depression.
Methods: Using data from the Rome Foundation Global Epidemiology Study, we analyzed 54,127 participants across 26 countries, including 2,195 patients with IBS. Clinical, dietary and psychological characteristics were assessed using validated questionnaires. Subgroup analyses compared IBS subtypes with FBDs, while mediation analyses (using the PROCESS macro and Baron and Kenny's method⁴) identified mediators of IBS-psychological distress relationship.

Results

As compared to patients with IBS-D, patients with IBS-C reported more severe pain characteristics, including prolonged pain episodes (50.7% vs. 47.0% of the time with pain lasting >30 minutes, p=0.030) and pain episodes that escalated to a sustained severe intensity (44.2% vs. 38.1%, p=0.026), frequently accompanied by back pain (36.7% vs. 30.9%, p<0.001). Regular use of prescribed pain medications was also more frequent in IBS-C (39.3%) than IBS-D (31.8%, p=0.004). In contrast, as compared to IBS-C, patients with IBS-D showed a stronger association of pain with changes in stool consistency (70% vs. 60% of time with pain, p<0.001) and frequency (mean 61.3% vs. 57.8% of time with pain, p=0.008). These associations remained significant in multiple regression models, which confirmed that IBS-C is more strongly linked to prolonged and escalating pain episodes, while IBS-D is more closely linked to pain associated with changes in stool frequency and consistency. As compared to FD, IBS-D patients reported greater dissatisfaction with bowel function (57.3±28.4 vs. 44.2±29.8, p<0.001), and more frequent loose stools (without constipation treatments) (60.0% vs. 50.0% of bowel movements, p<0.001), particularly after meals (60.0% vs. 40.0% of loose stools, p<0.001). IBS-C shows more severe constipation-related symptoms compared to FC (p<0.001). Mediation analyses revealed that concerns about bowel function, embarrassment discussing it, and work-related impairments partially mediated the relationship between IBS and psychological distress.

Conclusion

IBS-C is associated with more severe pain episodes, including prolonged and escalating pain, while in IBS-D pain is more strongly linked to bowel habit changes. These findings highlight the distinct clinical profiles of IBS subtypes and emphasize the need for personalized, multimodal management strategies. Identifying mediators of psychological distress in IBS can guide targeted interventions, improving patient outcomes.

References

1. Lacy, B. E. et al. Bowel Disorders. Gastroenterology (2016) doi:10.1053/j.gastro.2016.02.031.
2. Savarino, E. et al. Functional bowel disorders with diarrhoea: Clinical guidelines of the United European Gastroenterology and European Society for Neurogastroenterology and Motility. United European Gastroenterol J 10, 556–584 (2022).
3. Mearin, F. et al. Clinical Practice Guideline: Irritable bowel syndrome with constipation and functional constipation in the adult. Revista espanola de enfermedades digestivas 108, 332–63 (2016).
4. Baron, R. M. & Kenny, D. A. The moderator-mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations. J Pers Soc Psychol 51, 1173–82 (1986).

Introduction

Gastrointestinal involvement is common in patients with multiple sclerosis (MS). It is estimated that 35–54% of MS patients experience constipation, while 29–51% develop faecal incontinence (FI), with both conditions frequently coexisting¹. The underlying pathophysiology is complex, as MS can affect the central nervous system at multiple levels. Despite its high prevalence and significant impact on quality of life, few studies have specifically addressed anorectal dysfunction in these patients.
The aim of our study was to describe the clinical and manometric features of MS patients presenting with constipation and/or FI.

Aims & Methods

26 patients with MS were included. High-resolution anorectal manometry (HRAM; Medtronic®), following the London protocol, and balloon expulsion test (BET; Matla Systems®) were performed in all subjects. Reference values were derived from 20 healthy controls assessed at our centre (Table 1).

Table 1. HRAM Parameters in Healthy Subjects in left lateral decubitus

Results

Faecal incontinence was observed in 21 patients (80.8%), predominantly mixed (42.3%), complete (stool and gas; 34.6%), and with Wexner scores >9 in 26.9% of cases. Constipation was reported by 15 patients (57.7%), of whom 14 (53.8%) perceived obstructive defecation. Constipation and FI coexisted in 10 patients (38%). Urinary incontinence was also present in 17 patients (65.4%).
Manometric findings revealed a tendency towards resting anal sphincter hypotonia (67.06 ± 19.85 mmHg) and reduced maximum voluntary contraction pressure (median 105.35 mmHg [IQR 86.48–149.28 mmHg]). Median contraction duration was 30 seconds (IQR 8–32 s). Rectal sensitivity assessment showed median thresholds for first sensation at 55 cc (IQR 40–70 cc), second sensation at 125 cc (IQR 100–160 cc), and maximum tolerated volume at 170 cc (IQR 135–190 cc). Sensory abnormalities were identified in 11 patients (42.3%), 4 due to hypersensitivity (15.4%) and 7 (26.9%) due to hyposensitivity.
An impaired push manoeuvre was observed in 20 patients (83.3%): type I dyssynergic defecation (DD) in 5 patients (20.8%), type II in 5 (20.8%), type III in 4 (16.7%), and type IV in 6 (25%). BET confirmed dyssynergia in 10 patients (41.7%).
*Note: Results are expressed as mean ± standard deviation or median (interquartile range), depending on data distribution. Reference values are presented as mean ± standard deviation.*

Conclusion

FI was the most prevalent symptom, often coexisting with constipation and obstructive defecation. The tendency observed in manometric findings towards anal hypotonia and hypocontractility, as well as the presence of dyssynergia in a significant number of patients, may allow the selection of individuals suitable for targeted therapies.

References

1. Dibley L, Coggrave M, McClurg D, Woodward S, Norton C. "It's just horrible": a qualitative study of patients' and carers' experiences of bowel dysfunction in multiple sclerosis. J Neurol. 2017 Jul;264(7):1354-1361.