Introduction

High-resolution manometry (HRM) is routinely performed in an outpatient clinic setting. If intubation is not tolerated or if the LOS is not traversed, the test is often abandoned with no viable alternative option, thus impacting on therapeutic decisions. This study explores the option of intubating the catheter during endoscopy under the comfort of sedation and direct vision.

Aims & Methods

All patients who had HRM catheter insertion during endoscopy at a tertiary referral centre in London between Jan 2020 and April 2023 were collated and analysed. A consecutive equivalent number of standard unsedated HRM studies, as well as patients having standard diagnostic endoscopy at the same centre between Nov and Dec 2022 were included for comparison. Demographic data, symptom presentation, endoscopic technique and manometry diagnosis were analysed. All HRM studies attempted a full protocol of single water swallows and rice meal, undertaken only after confirmation that sedation had abated. The median integrated relaxation pressure (IRP) of single water swallows was used to categorise patients into those with and without a disorder of outflow. Oesophageal body function was defined according to the Chicago Classification of motility disorders¹.

Results

Of the 47 patients (68.1% F; 17-86 yrs) who were referred for endoscopic insertion (EI) of the HRM catheter, 42 (89.3%) were successfully intubated to the stomach. Of those, 33 (78.6%) were observed to pass through the pharynx and LOS with the endoscope, 4 (9.5%) required manual guidance through the oesophagus and LOS, whilst 5 (11.9%) required only observation of catheter passage through the pharynx. Overall, 41 (87.2%) patients completed the full swallow protocol. Indications for referral for EI included intolerance to standard insertion through the nares (52.4%), inability to breach the LOS resulting in a curled catheter (26.2%) and other reasons including septal deviation and psychiatric burden (21.4%). Similarly, of the contemporaneous 47 patients who had standard insertion (SI) of the HRM catheter in the outpatient setting (67.3% F, 23-80 yrs), 39 (82.9%) were successfully intubated and 33 (67.3%) completed the full swallow protocol. Symptoms were reproduced during the test protocol in both cohorts similarly (69.0% EI, n=42; 59.0% SI, n=39). EI patients required higher doses of sedation compared to a consecutive cohort of patients who attended for routine diagnostic endoscopy; mean Fentanyl 112.5µg (n=36) vs 78.7µg (n=47) p<.001, and Midazolam 4.9mg vs 3.4mg p<.001, respectively. The IRP was not significantly different between EI and SI regardless of LOS morphology; mean IRP in patients with no LOS outflow disorder (8.01mmHg, n=28 vs 6.05mmHg, n=35; p=.08), compared to those with an outflow obstruction (28.0mmHg, n=12 vs 23.1mmHg, n=5; p=.35). Overall motility diagnoses between the two cohorts are presented in Table 1.

Table 1: Diagnoses for HRM

Conclusion

Inserting the HRM catheter during endoscopy under sedation and direct vision enables oesophageal physiology testing for patients who might not have otherwise been able to receive motility assessment. The procedure is safe, feasible and is associated with no complications or adverse risk to date. Just as wireless pH monitoring can be a salvage for those who are unable to tolerate the pH catheter, this technique can fill an important gap in the investigation algorithm where motility testing would have otherwise been abandoned.

References

¹Yadlapati, Rena et al. “Esophageal motility disorders on high-resolution manometry: Chicago classification version 4.0^©.” Neurogastroenterology and motility : the official journal of the European Gastrointestinal Motility Society vol. 33,1 (2021): e14058. doi:10.1111/nmo.14058

Introduction

The adenoma detection rate (ADR) is the percentage of screening colonoscopies that detect at least one conventional adenoma verified by pathology. International guidelines recommend a minimum ADR of 25% (1,2), for every 1% increase in ADR reducing 3% and 5% the incidence of colorectal cancer and mortality, respectively (3). Increasing ADR under any context is highly desirable, so the primary outcome of our study is to compare the ADR using Endocuff versus indigo carmine staining.

Aims & Methods

A prospective, randomized, single-blind clinical trial was carried out on patients aged 45-85 years undergoing screening colonoscopy in a private tertiary hospital in Mexico City from December 2016 to September 2022. Patients were randomized 1:1 for Endocuff vision or indigo carmine group arms. The primary outcome was global ADR; secondary outcomes were ADR by segment, polyp detection rate (PDR) and serrated lesions detection rate (SDR).

Results

A total of 324 patients were analyzed, 163 in the Endocuff vision arm and 161 in the indigo carmine arm. The ADR was 46% (95% CI 54-38) in the Endocuff group and 52% (95% CI 60-44) in the indigo carmine group without significant difference (p=0.27), with a higher ADR in the right colon for the use of indigo carmine (p=0.06). In the subgroup analysis, there was a higher PDR in the indigo carmine group (69 vs 79%, p=0.03) but no significant difference between groups in advanced adenomas or SDR (p=0.23)

Table 1. Outcomes results

Conclusion

Any technique to improve ADR is useful and favorable over conventional colonoscopy, without a difference in the use of indigo carmine or Endocuff. In Mexico, ADR can be achieved as high as 46% to 52% with an added tool.

References

1. Rembacken B, Hassan C, Riemann JF, Chilton A, Rutter M, Dumonceau JM, et al. Quality in screening colonoscopy: Position statement of the European Society of Gastrointestinal Endoscopy (ESGE). Endoscopy. 2012;44(10):957–68.
2. Davidson KW, Barry MJ, Mangione CM, Cabana M, Caughey AB, Davis EM, et al. Screening for Colorectal Cancer: US Preventive Services Task Force Recommendation Statement. JAMA - Journal of the American Medical Association. 2021;325(19):1965–77.
3. Corley DA, Jensen CD, Marks AR, Zhao WK, Lee JK, Doubeni CA, et al. Adenoma Detection Rate and Risk of Colorectal Cancer and Death. New England Journal of Medicine. 2014;370(14):1298–306.

Introduction

Emerging evidence points towards a plausible link between psoriasis, a common chronic inflammatory skin disease, and inflammatory bowel disease (IBD), as both diseases share similar inflammatory pathways(1).

Aims & Methods

Our aim was to identify patterns and potential predictors for the development of IBD in a psoriasis patients cohort.
This retrospective electronic health records-based study utilized data from the Meuhedet Health Maintenance Organization (MHMO) which contains 20 years of continuous follow-up. Patents’ data were evaluated for demographic parameters, comorbidities, auto-antibodies, and medications used.
Prevalence and incidence of IBD were measured. The association between psoriasis and IBD was evaluated using both univariate and multivariate logistic regression models, with adjustments made for possible confounding factors. The prediction model was developed to identify predictors of IBD development in psoriasis

Results

Data between psoriasis patients (n=61,003) and age and gender-matched controls (n=244,012) was compared.
Among psoriasis patients, 2.5% were diagnosed with IBD, compared to 1.6% of controls (OR 1.57, 95%CI 1.48-1.67). The adjusted OR was 1.47 (95% CI 1.37-1.56), p<0.001. IBD was diagnosed before the onset of psoriasis in 51.9% and within 1 year of psoriasis onset in 7.2%. Predictors of IBD development in psoriasis patients were: older age (OR 1.01, 95%CI 1.01-1.02), male gender (OR 1.22, 95%CI 1.03-1.45), axial spondyloarthropathies (OR 1.78, 95%CI 1.29-2.45), severe psoriasis (OR 16.03, 95%CI 11.02-23.34), uveitis (OR 3.13, 95%CI 2.08-4.71), ASCA positivity (OR 10.71, 95%CI 7.38-15.55), and P-ANCA positivity (OR 7.71, 95%CI 2.04-29.04). The specific risk for IBD among psoriasis patients according to disease severity is shown in Table 1.
Decreased risk for IBD in psoriasis patients was observed in patients with obesity (OR 0.76, 95%CI 0.62-0.94), psoriatic arthritis (OR 0.49, 95%CI 0.34-0.72), phototherapy (OR 0.09, 95%CI 0.06-0.15), and methotrexate use (OR 0.13, 95%CI 0.08-0.21). The presence of ANA antibodies was not significantly associated with the risk of IBD within the psoriasis cohort.

Conclusion

Our study provides evidence for a significant association between psoriasis and IBD and identifies several predictors for the development of IBD in psoriasis patients. These findings may improve clinical decision-making and patients’ outcomes.

References

Li, Y., Guo, J., Cao, Z., & Wu, J. (2022). Causal Association Between Inflammatory Bowel Disease and Psoriasis: A Two-Sample Bidirectional Mendelian Randomization Study. Frontiers in immunology, 13, 916645. https://doi.org/10.3389/fimmu.2022.916645

Disclosure

None

Introduction

Colorectal adenomas are commonly found in individuals over the age of 50, but their occurrence in younger individuals is increasing. However, it is still unknown if colorectal cancer in young patients follow different pathways. Therefore, this study aims to compare the types of colorectal adenomas/lesions in individuals under the age of 50 versus those over 50.

Aims & Methods

To assess the differences in adenoma subtypes amongst individuals aged 50 and older versus those under the age of 50.

Results

488.767 screening colonoscopies between 2008 and 2023 were analyzed within the Austrian quality assurance program. 17.216 (3,5%) individuals were under and 471.551 (96,5%) were above. 14,3% (n=2.454) patients under 50 and 25,5% (n=120.018) above had adenomas. 11.8% (n=289) of precursor lesions within those under and 7,9% (9503) above, were Sessile serrated lesions (p<0,001). 3,3% (n=81) were traditional serrated adenomas (TSA) among those <50 and 1,1% (n=1.362) above (p<0,001). 12.7% (n=311) vs. 12.6%(n=15.120; p=0,92)) of adenomas were tubulovillous and 0,57% (n=14) vs. 0,76% (n=915) (p=0,28)were villous comparing <50a and >50a. 71,7% (n=1.759) of adenomas within individuals under 50 and 77,6% (n=93.118) above were tubular (p=0,12)

Conclusion

Individuals under 50 have a significant higher proportion of SSA and TSA but a significant lower proportion of tubular adenomas than those aged 50 and older.

Introduction

Recent societal guidelines suggest there is no role for hydrogen and methane breath testing (HMBT) to exclude small intestinal bacterial overgrowth (SIBO) in patients with diarrhoea predominant irritable bowel syndrome (IBS) and to treat symptoms with rifaximin empirically^1,2. However, a positive result for SIBO with lactulose HMBT has been shown to predict more favourable outcomes to rifaximin in patients with diarrhoea predominant IBS³. We wanted to investigate if symptoms and medical history can predict lactulose HMBT outcome hence justifying treatment of SIBO without a formal diagnosis.

Aims & Methods

A large questionnaire-based study was conducted in over 1000 patients of which 731 completed lactulose HMBT. The 26-item questionnaire included questions about medical history, symptoms, and pattern of symptoms, and we used this to identify any positive predictors for SIBO on HMBT. A positive lactulose HMBT was determined by a rise of ≥20 ppm in breath hydrogen from baseline within 90 minutes³. Breath samples were analysed using gas chromatography. Associations and predictors were calculated using chi square tests and logistic regression, respectively.

Results

Bloating (93.6%), abdominal pain (87.3%), and diarrhoea (80.3%) were the most common symptoms reported by those with a positive result for SIBO, but their duration, frequency and onset were no different to patients with a negative result (P > 0.05). There were no positive predictors for SIBO on lactulose HMBT based on symptoms, medications or medical history except for chronic low ferritin (P = 0.025).

Conclusion

This large questionnaire study has demonstrated that symptoms and medical history cannot predict HMBT outcomes for SIBO. Therefore, treatment of SIBO without a diagnosis confirmed on HMBT may lead to unnecessary antibiotic use and costs.

References

1. Vasant DH, Paine PA, Black CJ, Houghton LA, Everitt HA, Corsetti M, Agrawal A, Aziz I, Farmer AD, Eugenicos MP, Moss-Morris R, Yiannakou Y, Ford AC. British Society of Gastroenterology guidelines on the management of irritable bowel syndrome. Gut. 2021 Jul;70(7):1214-1240.
2. Savarino E, Zingone F, Barberio B, Marasco G, Akyuz F, Akpinar H, Barboi O, Bodini G, Bor S, Chiarioni G, Cristian G, Corsetti M, Di Sabatino A, Dimitriu AM, Drug V, Dumitrascu DL, Ford AC, Hauser G, Nakov R, Patel N, Pohl D, Sfarti C, Serra J, Simrén M, Suciu A, Tack J, Toruner M, Walters J, Cremon C, Barbara G. Functional bowel disorders with diarrhoea: Clinical guidelines of the United European Gastroenterology and European Society for Neurogastroenterology and Motility. United European Gastroenterol J. 2022 Jul;10(6):556-584.
3. Rezaie A, Heimanson Z, McCallum R, Pimentel M. Lactulose Breath Testing as a Predictor of Response to Rifaximin in Patients With Irritable Bowel Syndrome With Diarrhea. Am J Gastroenterol. 2019 Dec;114(12):1886-1893.

Introduction

Chronic Intestinal Pseudo-Obstruction (CIPO) is a rare disease characterized by a severe impairment of intestinal propulsive activity resulting in a clinical picture mimicking a mechanical intestinal obstruction despite the absence of any physical obstruction. Velusetrag (VEL) is a highly selective oral 5-hydroxytryptamine type 4 receptor (5-HT4R) agonist that enhances peristalsis, stimulates intestinal secretion and inhibits gastrointestinal visceral sensitivity via acetylcholine and calcitonin gene-related peptide released from motor and sensory neurons, respectively. This phase II, multicenter, double-blind, placebo-controlled, 2 treatments, 4 periods, multi-crossover (N-of-1) trial investigates the efficacy and safety of VEL in CIPO patients.

Aims & Methods

Seventeen patients with idiopathic or secondary (to primary neurodegenerative disorders) CIPO with at least 30% of their daily caloric intake from oral nutrition were treated for 4 periods of 4 weeks each with either VEL 15 mg once daily or placebo (PLA), with a washout period of 2 weeks between treatment periods. Each cycle with two periods assigned to either VEL or PLA is considered as a pair of observations. Analysis was performed on the evaluable pairs (i.e., evaluation available both for VEL and PLA within cycle). Each subject could be evaluated twice, once for each cycle, thus, each subject could contribute to 0, 1 or 2 observations for each treatment. The present analysis was performed on 15 patients, assessed as responders or naïve to 5-HT4R agonists. The number of pseudo-obstructive episodes and stool type (Bristol stool scale) were assessed during the entire study.

Results

A 50% reduction in the number of pseudo-obstructive episodes in VEL (n=4) vs PLA (n=8) was detected in 30 evaluable pairs of observations. During VEL treatment, pseudo-obstructive episodes occurred once in 2 patients and twice in 1 patient; during PLA treatment 7 patients experienced 1 episode and 1 during wash-out period after PLA. Complete normalization of constipation was observed only with VEL. In 23 evaluable pairs, all 4 observations with constipation on VEL at pre-treatment had normal stools at end of treatment (from Bristol stool type 1-2 to 3-4); additionally, observations with normal stools increased from 3 (pre-treatment) to 6 (end of treatment). In contrast, all 3 observations with constipation on PLA at pre-treatment remained constipated at end of treatment and other 2 observations with diarrhea at pre-treatment shifted to constipation at the end of treatment (Tab. 1). These results did not reach statistical significance due to limited sample size. The number of subjects with treatment emergent adverse events was similar between VEL and PLA. No cardiovascular adverse reactions or serious treatment emergent adverse events were observed in both treatment groups.

Conclusion

​​​​​​​​A VEL prokinetic effect was confirmed by a decreased number of pseudo-obstructive episodes and a normalization of constipation, two main clinical features of CIPO. VEL was also well-tolerated and safe, with no serious drug-related adverse event reported.

Disclosure

Publications management support was provided by PharmaGenesis London, London, UK, and was funded by Alfasigma S.p.A.

This study was sponsored by Alfasigma S.p.A.

Stanghellini V is a member of advisory boards and/or is a speaker for Alfasigma, Bayer, GE Healthcare and Vibrant Pharma; and receives research support from Alfasigma.

Tack J and Malagelada C have relevant financial relationship(s) to disclose: Alfasigma S.p.A.; consultancy and honoraria.

Grimaldi M, Giovannini R, Gentile E, Scuderi V, Manzoni S, Pasquali E, Costantini C, Barone M and Pellacani A have relevant financial relationship(s) to disclose: Alfasigma S.p.A.; employees.

All other authors declare that they have no relevant conflicts of interest to disclose.

Introduction

Mortality of acute mesenteric ischemia (AMI) is closely correlated with the development and extent of irreversible transmural intestinal necrosis (ITIN). In this context, the surgical assessment of small bowel viability is difficult, subjective (visual) and invasive. In order to better identify high-risk patients justifying an immediate surgical evaluation, the non-invasive Clichy score was developped in 2017 (Nuzzo et al. Am J Gastroenterol 2017). The aim of this study was to evaluate the diagnostic performance of this score.

Aims & Methods

The development cohort included 67 patients with AMI admitted to our center between 2009 and 2015, with a Clichy score including 3 independent factors (organ failure, elevation of plasma lactate > 2 mmol/L, and intestinal dilation on CT scan > 25mm; area under the ROC curve [AUROC] = 0.94 [95% confidence interval: 0.87–1.00]). The present validation study prospectively included patients admitted to our center for AMI between 2016 and 2018. The presence of ITIN was defined histologically as previously published. The diagnostic performance of the score was assessed by AUROC in the total cohort, and in the AMI subgroups of arterial and venous origin.

Results

52 patients (mean age 65, 37% women) were included. Arterial and venous occlusion induced AMI occurred in 65% and 35% of cases, respectively. ITIN was confirmed in 14 patients (27%). Organ failure, elevation of plasma lactate > 2 mmol/L, and intestinal dilatation > 25 mm was observed in 17 (33%), 15 (29%) and 12 ( 23%) of patients, respectively. The AUROC for the diagnosis of ITIN by the Clichy socre was 0.90 (95% CI = 0.81 – 0.98). In the presence of 0, 1, 2 and 3 factors, the risk of ITIN was 0%, 14%, 55% and 75%, respectively (Figure). In subgroup analyses, the AUROC for the diagnosis of ITIN was 0.96 (0.89 – 1.00) in arterial AMI, and 0.77 (0.53 – 0.85) in venous AMI. In arterial AMI, the risk of ITIN was respectively 0%, 13%, 67% and 100% in the presence of 0, 1, 2 and 3 factors. In venous AMI, the risk of ITIN was respectively 0%, 17%, 50% and 50% in the presence of 0, 1, 2 and 3 factors. The negative predictive value (NPV) of a score of 0 was 100% in both types of AMI. The positive predictive value (PPV) of a score of 3 was 100% in arterial AMI, and 50% in venous AMI.

Conclusion

This prospective study is the first which validates a non invasive diagnostic score of ITIN in the setting of AMI. The diagnostic performance of the score was satisfactory, especially in AMI of arterial origin. These results suggest that these factors should prompt laparotomy consideration if present. In the subgroup of venous AMI, further studies seem necessary to identify other risk factors.

Disclosure

MSD Avenir grant