Introduction

Non-invasive assessment of liver fibrosis is central to managing chronic liver disease. FibroScan® (transient elastography), FIB-4, and APRI are widely used, but obesity may impair FibroScan® performance by altering probe penetration and signal quality, particularly in metabolic liver disease. This may lead to fibrosis overestimation and inappropriate clinical decisions.

Aims & Methods

This study aimed to evaluate the concordance between FibroScan®, FIB-4, and APRI in assessing advanced liver fibrosis, stratified by BMI, and to identify predictors of diagnostic discordance—particularly in obese patients where FibroScan® performance may be compromised.
We retrospectively included 120 consecutive patients with valid FibroScan® measurements (≥10 acquisitions, IQR/median <30%) and available FIB-4, APRI, and BMI data. Patients with confounders (ascites, cytolysis ≥3× ULN, cholestasis, or hepatic mass) were excluded.
Advanced fibrosis was defined using validated thresholds:

• FibroScan® ≥10.5 kPa (AASLD/EASL)

• FIB-4 >2.67

• APRI ≥1.5
  Concordance between FibroScan® and FIB-4 was assessed via weighted kappa, APRI serving as a third comparator. Patients were stratified by BMI (<30 vs ≥30 kg/m²). Predictors of discordance were analyzed using logistic regression.

Results

Among 120 patients (mean age 47.2 ± 14.5 years; 55% female; mean BMI 26.3 ± 4.9 kg/m²), 63% were non-obese. Advanced fibrosis was diagnosed in 34% (FibroScan®), 28% (FIB-4), and 20% (APRI).
In non-obese patients (n=76), concordance between FibroScan® and FIB-4 was strong (κ = 0.75), with only 11.2% discordance. APRI confirmed FibroScan® classification in 87% of cases.
In obese patients (n=44), concordance dropped sharply (κ = –0.27), with 63.6% discordance. APRI also poorly agreed with FibroScan® (κ = 0.09), reinforcing the discordance. Most discrepancies involved FibroScan® indicating advanced fibrosis not supported by serum markers. Logistic regression confirmed BMI ≥30 as an independent predictor of discordance (OR 2.63; 95% CI 1.55–4.67; p < 0.001); age and sex were not associated.

Conclusion

FibroScan®, FIB-4, and APRI show good concordance in non-obese patients. However, obesity significantly impairs FibroScan® reliability, leading to frequent fibrosis overestimation. These findings support BMI-adapted strategies, including XL probe use or integration of serum markers, to improve diagnostic accuracy in metabolic liver disease.

Clinical Case Summary

Background: Percutaneous endoscopic gastrostomy (PEG) tubes are commonly used for long-term enteral nutrition in critically or chronically ill patients [1]. Buried bumper syndrome (BBS), a rare but serious complication, occurs when the internal bumper migrates along the stoma tract, leading to tissue ischemia, infection, and potential tube dysfunction [2,3]. BBS typically manifests around 18 months post-placement, with acute presentations exceptionally rare [4]. This case highlights an unusual early onset of BBS, emphasizing the importance of vigilant post-procedural care [5].
Case report: An 83-year-old male with multiple comorbidities, including progressive oropharyngeal dysphagia following cervical spine surgery, underwent PEG tube placement for enteral nutrition. Postoperatively, mild oozing was managed by tightening the bumper. Twelve days later, erythema and pressure necrosis were noted due to excessive tightness, prompting loosening. Three weeks post-placement, localized cellulitis developed and was treated with antibiotics. Two months postoperatively, the PEG tube became dysfunctional, and endoscopic evaluation revealed a partially buried bumper. A minimally invasive surgical approach, assisted endoscopically, was performed to extract the bumper and replace the tube with a balloon G-tube. The revised PEG tube functioned effectively, with no recurrence of complications.
Conclusion: This case underscores the importance of early recognition and management of BBS, even in the acute postoperative period [4,7]. Minimally invasive techniques, combined with proper bumper positioning and patient education, are crucial for preventing and managing this complication [3,6]. Vigilant monitoring of PEG sites and timely intervention can significantly reduce morbidity and improve outcomes in patients with BBS [2,7].

References

1. Blumenstein I, Shastri YM, Stein J. Gastroenteric tube feeding: Techniques, problems and solutions. World J Gastroenterol. 2014;20(26):8505–24.
2. Cyrany J, Rejchrt S, Kopacova M, Bures J. Buried bumper syndrome: A complication of percutaneous endoscopic gastrostomy. World J Gastroenterol. 2016;22(2):618–27.
3. Pérez R, De La Serna C. Buried bumper syndrome: A critical analysis of endoscopic release techniques. World J Gastrointest Endosc. 2019;11(9):611–7.
4. Pinho J, Libânio D, Pimentel-Nunes P, Dinis-Ribeiro M. The challenging acute buried bumper syndrome: A case report. GE Port J Gastroenterol. 2018;25(3):151–4.
5. Satiya J, Marcus A. The buried bumper syndrome: A catastrophic complication of percutaneous endoscopic gastrostomy. Cureus. 2019;11(3):e4275.
6. Maly O, Bichard P. Endoscopic management of buried bumper syndrome using a guidewire and external traction: a novel technique. Acta Gastro-Enterol Belg. 2023;86(1):13–6.
7. Venu RP, Brown RD, Pastika BJ, Erikson LW. The buried bumper syndrome: a simple management approach in two patients. Gastrointest Endosc. 2002;56(4):582–4.

Disclosure

Dear Editors,
I, Evelyn Inga, hereby declare that I have no financial, professional, or personal conflicts of interest.
I affirm that I have no affiliations, financial interests, personal relationships, or commitments that could influence my impartiality in reviewing, conducting, or overseeing our study. Additionally, I confirm that I will uphold the highest ethical standards in compliance with institutional and federal regulations.
If any potential conflict arises, I will promptly disclose it to the United European Gastroenterology Association. Please let me know if any further documentation is required.
Sincerely,
Evelyn Inga, MD

Clinical Case Summary

A 59-year-old man was admitted with painless jaundice. Laboratory data revealed elevated liver enzymes and hyperbilirubinemia (ALT 95UI/L, AST 54UI/L, ALP 550UI/L, total bilirubin 6mg/dL and direct bilirubin 4.6mg/dL). CT confirmed an unresectable 4cm perihilar infiltrative lesion with extensive portal vein invasion and cavernous transformation. An US-guided biopsy of the lesion followed by percutaneous transhepatic cholangiography were performed, allowing palliative biliary drainage with non-covered metal stents. Nevertheless, biopsy sample histopathology yielded no intersected neoplastic tissue.
Given the strong suspicion of malignancy and the need for histopathology to guide systemic treatment, endoscopic retrograde cholangiopancreatography (ERCP) with cholangioscopy-guided biopsies was proposed. The procedure started by conventional biliary cannulation. Cholangiography revealed the metallic stents in situ crossing the hilum. Biliary endoscopic sphincterotomy was performed and a 3.2mm cholangioscope (EyeMAX™) was successfully introduced. The common bile duct and the hepatic ducts were carefully explored advancing the cholangioscope through the stents into the intrahepatic ducts. Detailed inspection of the biliary mucosa identified areas of pseudopolypoid appearance covering the stent body in the hilar region with marked friability and aberrant vascularization. Cholangioscopy-guided biopsies were laboriously performed through the mesh of the metal stents using a 1mm biopsy forceps (EyeMAX™ biopsy forceps). No displacement or damage to the stents were observed. Histology confirmed a moderately differentiated cholangiocarcinoma, and palliative chemotherapy could be started.
Biliary non-covered metal stents should only be used after a definite histologic diagnosis of cancer is stablished. Despite the potential technical limitations of this unreported approach, targeted biopsies through the mesh of metallic stents seem effective without compromising stent integrity.

References

Cholangioscopy images.
Fluoroscopy images.
Histopathology images.

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

Patients with diabetes mellitus (DM) are at an increased risk of developing cardiovascular disease (CVD). Hepatic steatosis is common among patients with DM, but its impact on CVD risk remains unclear.

Aims & Methods

This study aimed to prospectively assess the association between a reduction in hepatic steatosis and a lower risk of CVD in patients with DM.
A total of 323 patients with DM were prospectively enrolled from January 2022, after excluding those with viral hepatitis, overt cirrhosis, and cancer. Clinical measurements and CVD history were recorded. The following parameters were assessed: body weight (BW), body mass index (BMI), waist circumference (WC), laboratory data (aspartate aminotransferase, alanine aminotransferase, gamma-glutamyl transferase, platelet count, hemoglobin A1C, cholesterol, and triglycerides), presence of hypertension (HTN), dyslipidemia, alcohol consumption, smoking status, liver stiffness measurement (LSM by FibroScan®), and current anti-DM medications. Hepatic steatosis was quantified using the controlled attenuation parameter (CAP) measured by FibroScan® at baseline and after two years. CVD was defined as ischemic heart disease or ischemic/hemorrhagic stroke.

Results

A total of 277 patients completed the two-year follow-up and underwent repeat CAP assessment. The mean age was 57±12 years, and 56.3% were male. The baseline mean CAP was 274±18 dB/m. A history of CVD was present in 86 (31%) patients, while 6 (3.2%) developed new CVD events during follow-up. Among the new CVD cases, 3 were cardiac events, and 3 were neurovascular events. CAP scores decreased in 176 patients (d-CAP group) and increased in 101 patients (i-CAP group). The mean CAP change was -33±29 dB/m in the d-CAP group and +24±18 dB/m in the i-CAP group. The mean age was higher in the d-CAP group than in the i-CAP group (58±12 vs. 55±12 years, p=0.012). The baseline mean CAP was higher in the d-CAP group than in the i-CAP group (284±50 vs. 255±47 dB/m, p<0.001). There were no significant differences in male proportion (58% vs. 53.5%, p=0.468), BW (71±14 vs. 73±17 kg, p=0.258), BMI (26.1±4.2 vs. 27±4.9 kg/m², p=0.14), WC (89±10 vs. 90±12 cm, p=0.397), laboratory data, HTN (56.8% vs. 48.5%, p=0.182), dyslipidemia (66.5% vs. 64.4%, p=0.72), alcohol consumption (24.4% vs. 21.8%, p=0.616), smoking status (48.9% vs. 43.6%, p=0.395), or baseline LSM (6.9±3.8 vs. 6.9±3.5 kPa, p=0.988) between the two groups. The use of metformin (93.2% vs. 93.1%, p=0.972) and pioglitazone (2.3% vs. 2%, p=1.0) did not differ significantly, but insulin use was lower in the d-CAP group than in the i-CAP group (5.1% vs. 12.9%, p=0.022). When stratified by CAP change, the incidence of new CVD was 0% (0/55) in patients with CAP reduction of ≤-40 dB/m, 2% (4/201) in those with changes between -40 and +40 dB/m, and 9.5% (2/21) in those with CAP increases of ≥+40 dB/m (p=0.037).

Conclusion

Hepatic steatosis, as measured by CAP, can change dynamically in patients with DM. Although this was an observational study, a marked decrease in CAP score was associated with a lower risk of CVD in patients with DM. Therefore, CAP monitoring may be a valuable tool for assessing CVD risk. Efforts to reduce hepatic steatosis, as reflected by CAP reduction, may contribute to CVD prevention in this population.

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.