Introduction

Cyclic vomiting syndrome (CVS) is a disorder of gut-brain interaction defined by episodes of uncontrollable vomiting and retching. CVS has four phases (inter-episodic, prodrome, emetic, recovery) and affects both children and adults. There is a lack of published qualitative research on disease-related and phase-specific symptoms that impact patients with CVS.

Aims & Methods

Two qualitative, cross-sectional, observational interview studies were conducted in adults (18-65 years) and adolescents (12-17 years) with CVS. The studies aimed to explore the patient experience, identify the symptoms and understand their relevance to patients with CVS. The two studies included participants clinically diagnosed with CVS and followed at the tertiary care CVS programs at Froedtert hospital (adults) and Children’s Wisconsin (adolescents). Adolescents participated in a dyad interview with their caregiver or separately. Interviews were conducted remotely using a semi-structured interview guide and analysed with an “open coding” approach using ATLAS.ti 9.0 (adults) or 22.0 (adolescents).

Results

Semi-structured concept elicitation interviews (each up to 90 minutes long) were conducted with 13 adults (mean ± SD age 45.3 ± 13.1 years) and 15 adolescents (mean ± SD age 14.6 ± 1.8 years) by professional qualitative interviewers. Each participant described their symptoms during the prodrome and emetic phases. Most frequently reported symptoms during the prodrome were nausea (92.3%), anxiety (76.9%) and abdominal pain (69.2%) in adults; and nausea (100%), abdominal pain (73.3%), headache (73.3%) and pale skin (73.3%) in adolescents. During the emetic phase, the most frequently reported symptoms were nausea (100%), tiredness (100%), dry heaves (100%), vomiting (92.3%) and retching (92.3%) in adults; and nausea (100%), vomiting (100%), abdominal pain (93.3%), dehydration (86.7%), tiredness (86.7%) and light-headedness (86.7%) in adolescents. The patients most frequently reported nausea (5/13 adults, 6/15 adolescents) and vomiting (5/13 adults, 5/15 adolescents) as the most bothersome CVS symptom. Adults reported anxiety (associated with an impending vomiting episode; 5/13); missing work (2/13); inability to: perform daily tasks (1/13), plan their life (1/13), or parent to their full capacity (1/13); being homebound (1/13); reduced emotional well-being (1/13); and avoiding events (1/13) as the most bothersome impact of CVS symptoms. Adolescents reported impact on school (7/13 with data); missing out on sports (4/13); impacts on: social activities (4/13), sleep (1/13), friendships (1/13), or emotions (1/13); and anxiety (1/13) as the most bothersome impact of CVS symptoms (some provided >1 response). Caregivers reported the emotional impact of seeing their child suffer from CVS (5/11 with data); impact on: their child’s schooling (3/11), social activities (2/11); sports, friends/social activities, effect on their child’s future, work, daily planning, and travel planning (1/11 each) as the factor most difficult for them or their family.

Conclusion

Patients with CVS experience considerable gastrointestinal as well as extra-intestinal symptoms during both the prodrome and emetic phases. The majority suffer from nausea, vomiting and abdominal pain; the associated anxiety in adults is also notable. The study also confirmed major impact of CVS on daily life such as work/school absences, lost time with family/friends and reduced emotional well-being. CVS also markedly affects caregivers to patients with CVS.

Disclosure

Katja Kovacic reports medical advisory board from AbbVie, and is a consultant for Neurogastrx. Yaozhu J. Chen, Melody Wu, Camilla A. Richmond and James Williams are employees of the study sponsor, Takeda, and hold Takeda stock or stock options. Danielle Rodriguez is an employee of Evidera, which were contracted by Takeda for work relating to this study. Karin S. Coyne is an employee of Evidera, which were contracted by Takeda for work relating to this study, and a scientific consultant to Takeda. Thangam Venkatesan reports consultancy fees from Takeda.

Introduction

The extent of gastric atrophy(GA) is closely related to the incidence of Intestinal-type gastric cancer (GC). According to the Kimura-Takemoto classification, determining whether the atrophy extends beyond the cardia is key to assess the extent of GA. However, there is significant difficulty in determining whether the cardia is atrophied under endoscopy.

Aims & Methods

This study developed a novel artificial intelligence (AI)-assisted white light endoscopy system for identifying the cardia part and diagnosing cardia atrophy . In this multicenter study, patients undergoing upper gastrointestinal endoscopy at 5 hospitals in China were prospectively included between November 2022 and December 2024. Among them, a total of 895 patients from 2 units were assigned to the training and validation sets (292 with cardia atrophy and 603 without cardia atrophy) to establish a cardia atrophy diagnostic model. 220 patients from our unit (84 with cardia atrophy and 136 without cardia atrophy) were included in the internal test set. Additionally, a total of 354 patients from 3 other units were included in the external test set (106 with cardia atrophy and 248 without cardia atrophy). In the internal and external test sets, 3 senior and 3 junior endoscopists made online diagnoses, comparing the performance differences between physicians with different levles of experience and the AI-assisted cardia atrophy detection system.

Results

This study established a AI-assisted cardia atrophy diagnostic model and tested its diagnostic performance with multicenter image data in internal and external tests. In the internal test dataset, the accuracy, sensitivity, and specificity of the AI-assisted system were 0.927, 0.941, and 0.919, respectively, with a PPV of 0.878, NPV of 0.962, and AUC of 0.967. In the external test dataset, the accuracy, sensitivity, and specificity were 0.918, 0.894, and 0.931 respectively, with a PPV of 0.874, NPV of 0.943, and AUC of 0.953. Further comparison of the diagnostic efficiency of the AI-assisted system with endoscopists of different levels of experience revealed that both in the internal and external test set, the diagnosis accuracy, sensitivity, specificity, PPV, and NPV of the AI-assisted system were all higher than those of senior endoscopists. TheAI-assisted cardia atrophy diagnostic ROC curve area (AUC) was 0.967 and 0.953 in the internal and external test sets, respectively. Heat map analysis further showed a high consistency between theAI-assisted system and endoscopists in cardia atrophy diagnosis.

Conclusion

Our newly developed AI-assisted cardia atrophy diagnostic system shows superior performance in identifying cardia atrophy compared to senior endoscopists, and can be used to guide white light endoscopic judgment and targeted biopsies for cardia atrophy.

Introduction

Piecemeal endoscopic mucosal resection (pEMR) is the preferred treatment for large non-pedunculated colorectal polyps (LNPCPs)[1,2]. A major limitation of pEMR is residual or recurrent adenoma (RRA), which was reported to in 15%-30% of cases at first surveillance colonoscopy (SC1)[3], performed 3-6 months after the index procedure, but is reduced to the range of 3%-5% by applying ablative measures to the post-EMR resection margin[4].

Aims & Methods

This study aimed to evaluate the effects of late SC1 on RRA.
This is an analysis of a prospectively collected cohort of adult patients referred for pEMR at two academic centers in Israel, from 2016 to 2023. We included all patients who underwent pEMR of LNCPCs and completed SC1.
We compared outcomes between patients who completed early SC1 at 3-6 months following the index procedure with patients who completed late SC1 later than 6 months. All procedures and surveillance colonoscopies were performed by experienced endoscopists trained in pEMR using high-definition scopes. EMR was followed by thermal ablation of the entire mucosal defect margin with snare soft tip coagulation, as previously described[4].
Scar evaluation at SC1 was performed with high-definition white light and chromoendoscopy. Our primary endpoint was RRA at SC1.
Analyses were performed per lesion. We compared baseline parameters and outcome rates between groups, and performed multivariate analysis to assess the adjusted association of months to SC1 with RRA.

Results

We analyzed 516 lesions that underwent index pEMR resection and subsequent SC1. Baseline parameters and recurrence rates are presented in Table 1. The early SC1 group (n=371) underwent SC1 at a mean of 5.1 months versus a mean of 11.1 months in the late SC1 group (p<0.01; Table 1). Polyp size in the early SC1 group was significantly larger than that in the late SC1 group (mean size 35.9 mm [SD 13.9] vs. 32.1 mm [SD 12.4], p<0.01; Table 1). The distribution of lesion location, granularity differed between the groups (Table 1). However, there were no significant differences in lesion Paris classification or rates of high grade dysplasia (Table 1).
We found no statistically significant difference in the rate of recurrence at SC1 between the two groups (6.3% in the standard group versus 4.8% in the delayed group, p=0.64). Additionally, a sub-analysis comparing the early SC1 group to patients with very late SC1 (>12 months – mean time to SC1 17.9 (SD [5.4] months) and did not reveal significant difference in recurrence at SC1 (6.2% in the early SC1 vs 6.3% in the very late group, p=1).
Multivariate analysis, adjusted for lesion size, location, and high-grade dysplasia, showed that time to SC1 was not significantly associated with RRA (odds ratio 1.05, 95% confidence interval 0.98-1.13).

TABLE 1. Comparison of baseline variables and outcome between the early and late SC1.

Conclusion

Late SC1 is not associated with an increased RRA. Hence, we suggest that high-quality pEMR with margin ablation may alleviate the need for early SC1, thereby reducing healthcare and patient burdens. Further interventional studies are required.

References

[1] Ferlitsch M, Moss A, Hassan C, et al. Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy 2017; 49: 270–297. doi:10.1055/S-0043-102569/ID/JR15335-1/BIB
[2] Shaukat A, Kaltenbach T, Dominitz JA, et al. Endoscopic Recognition and Management Strategies for Malignant Colorectal Polyps: Recommendations of the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology 2020; 159: 1916-1934.e2. doi:10.1053/j.gastro.2020.08.050
[3] Belderbos TDG, Leenders M, Moons LMG, et al. Local recurrence after endoscopic mucosal resection of nonpedunculated colorectal lesions: Systematic review and meta-analysis. Endoscopy 2014; 46: 388–400. doi:10.1055/S-0034-1364970/ID/JR910-7/BIB
[4] Klein A, Tate DJ, Jayasekeran V, et al. Thermal Ablation of Mucosal Defect Margins Reduces Adenoma Recurrence After Colonic Endoscopic Mucosal Resection. Gastroenterology 2019; 156: 604-613.e3. doi:10.1053/j.gastro.2018.10.003

Disclosure

The authors report no conflict of interests

Introduction

Short bowel syndrome (SBS) is a severe complication of extensive small intestinal resection, most commonly occurring in Crohn’s disease (CD), a chronic inflammatory disorder defined by transmural immune infiltration. Cytokines and chemokines are central mediators in the immune cascade driving intestinal inflammation and tissue damage^1,2. Despite advances in care, no biomarkers currently predict SBS onset or progression to intestinal failure (IF). Profiling systemic cytokine and chemokine signatures may thus offer novel insight into disease trajectory and risk stratification.

Aims & Methods

This study investigates circulating inflammatory mediators in patients with established IF/SBS and CD patients at high risk of progression. A total of 150 patients with CD were enrolled and stratified into five groups based on intestinal function and surgical history: A1, SBS with IF requiring parenteral nutrition (PN) or intravenous fluids; A3, SBS without IF and inactive disease; B, high risk of IF with multiple or extensive resections; C1, low risk for IF with no history of resection; and C2, low risk for IF with prior resection. Serum cytokine and chemokine profiles were quantified at baseline (T0) and after six months (T6) using the human 27-PLEX multiplex immunoassay.

Results

Serum cytokines and chemokines profiling at baseline (T0) and after six months (T6) revealed distinct inflammatory patterns across the study groups. Patients with SBS and IF (group A1) showed persistently elevated levels of IP-10, IL-12, MIP-1α, and G-CSF, reflecting sustained immune activation. Whereas, patients at high risk of IF (group B) displayed increased Eotaxin, bFGF, IL-15, and IL-6, indicative of subclinical inflammation and possible tissue remodelling.
A general reduction in cytokine levels was observed at T6, though anti-inflammatory mediators remained minimally modulated, suggesting ongoing low-grade inflammation. Comparisons between groups highlighted divergent cytokine signatures correlating with disease severity and nutritional support requirements.

Conclusion

These findings suggest that specific circulating cytokines may serve as potential biomarkers for early identification of patients at risk of IF. The differential expression patterns observed across groups support their relevance in stratifying disease severity in CD and SBS. Further large-scale studies are needed to validate these preliminary results and to fully establish their prognostic significance.
Funded by: 2.1 “Rafforzamento e potenziamento della ricerca biomedica del SSN”, finanziato dall’Unione europea – NextGenerationEU, CUP C53C22001140007. 2022 PNRR Project “Changing the future of intestinal failure in intestinal chronic inflammation: towards innovative predictive factors and therapeutic targets” code: PNRR-MAD-2022-12376791.

References

1. Friedrich M, Pohin M, Powrie F. Cytokine Networks in the Pathophysiology of Inflammatory Bowel Disease. Immunity. 2019;50(4):992-1006. doi:10.1016/j.immuni.2019.03.017
2. Singh UP, Singh NP, Murphy EA, et al. Chemokine and cytokine levels in inflammatory bowel disease patients. Cytokine. 2016;77:44-49. doi:10.1016/j.cyto.2015.10.008

Introduction

Ulcerative colitis (UC) is a chronic, idiopathic inflammatory bowel disease (IBD), with mucosal inflammation affecting the rectum (proctitis, E1), left side of the colon (E2), or whole colon (pancolitis, E3). Proctitis is considered a mild disease, and often excluded from clinical trials due to heterogeneity in accessing the affected area of the colon. Proximal extension of the disease is associated with a more severe clinical course. We compared the disease burden of patients with UC according to disease extent.

Aims & Methods

THEFAR is a cross-sectional, observational, multicentre study, including adult patients with UC treated with advanced therapy (AT; biologics or Janus kinase inhibitors). Gastroenterologists across 41 centres included consecutive patients during routine clinic visits. They completed medical and therapeutic management data, including disease activity (partial Mayo score) using an electronic case report form (eCRF). Patients completed self-reported quality of life (EQ-5D-5L), disability (IBD-Disk), incontinence (Wexner score), bowel urgency (Urgency Numeric Rating Scale, UNRS), and Work Productivity and Activity Impairment UC (WPAI:UC) questionnaires.

Results

293 patients with UC (mean age 44 ± 16 years; 50% [147/293] male) were enrolled, with 292 self-reported questionnaires returned for analysis; 45 (15%) patients had proctitis (E1), 117 (40%) left-side colitis (E2), and 131 (45%) extensive colitis (E3). Former smokers were more common in E2 (25%) and E3 (28%) than E1 (11%) subgroups (p=0.01). Comorbidities, including chronic rheumatological disease and cardiovascular diseases, were similar across all subgroups (p>0.05). Disease duration was related to the extent of disease: mean duration of 5.3 years (E1) to 8.8 years (E3) (p=0.02). Age at diagnosis was lowest in E3 (33 years) compared to E1 and E2 (38 years each) subgroups (p=0.02). Regardless of subgroup, there was a similar incidence of flares over the past year, presence of extra-intestinal manifestations, and disease activity per partial Mayo score (all p>0.05). There was no proof of difference in current treatment allocation, duration or lines of advanced therapies, or corticosteroid use (p>0.05 for all [except golimumab]) between subgroups. The proportions of hospitalized patients were significantly different in subgroups: E1 (11%), E2 (21%), and E3 (46%) (p<0.0001).
There was no between-group difference for EQ-5D-5L, IBD-Disk, or WPAI:UC scores (all p>0.05). UC-related patient-reported outcomes were similar across subgroups according to both the Wexner score (p>0.05) and UNRS (p>0.05; Table).

Conclusion

In this cohort of patients with UC treated with AT, there was no association between the extent of disease and quality of life, disability, treatment allocation, work impairment, incontinence, or bowel urgency. However, the extent of disease was associated with hospitalizations. Patients with proctitis treated with AT experience similar disease burden and require a comparable level of treatment as those with left-sided colitis and pancolitis.
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Disclosure

M.F. has received lecture/consultant/travel support fees from Abbvie, MSD, Ferring, Tillots, Takeda, Sandoz, Fresenius, Arena, Pfizer, Amgen, Biogen, Gilead, Galapagos, Janssen
V.G., I.R., and I.J. are employees and minor shareholders of Eli Lilly and Company Ltd.
N.E. is an employee and minor shareholder of Eli Lilly and Company Ltd and reports previous employment and minor shareholdings with AbbVie and Gliead Science.
R.A. has no conflicting interests to declare.