Clinical Case Summary

Chronic reservoiritis is a frequent complication in ulcerative colitis (UC) patients with an ileoanal reservoir, affecting 30–50%. Many cases are refractory to conventional therapies, including biologics. Combined therapy emerges as a promising alternative.
Case 1: A 53-year-old male with UC and an ileoanal reservoir since 1988 developed chronic reservoiritis in 2014. After losing response to infliximab and adalimumab, he achieved stability with vedolizumab until 2021 but later lost response. Ustekinumab failed to induce a response. Vedolizumab was reintroduced with tofacitinib, achieving remission and allowing tofacitinib dose reduction. After 24 months, an attempt at monotherapy led to a mild flare, controlled by reintroducing vedolizumab, maintaining remission (PDAIm 0). The only adverse event was chronic pharyngitis.
Case 2: A 47-year-old male with UC and an ileoanal reservoir since 2000, also diagnosed with axial spondyloarthropathy, developed chronic reservoiritis in 2008, refractory to infliximab, adalimumab, and azathioprine. After a joint flare in 2018, vedolizumab and tofacitinib failed. In 2019, ustekinumab was introduced, achieving control. Fifteen months later, a joint flare prompted upadacitinib, leading to symptom control. In 2023, worsening digestive symptoms (PDAIm >5) led to combined upadacitinib and ustekinumab. After four weeks, clinical control was achieved, with biomarkers normalizing in five months. After 24 months, remission was maintained (PDAIm 0), with no adverse effects despite prior pulmonary embolism.
Conclusion: Refractory chronic reservoiritis remains a challenge, particularly in multi-refractory patients or those with IMIDs. Combining biologics with small molecules may optimize disease control and allow JAK inhibitor dose reduction. Although infections are the most common adverse events, none were observed in these cases. Further research is needed to assess long-term outcomes and refine its role in complex cases.

References

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2. Effectiveness and safety of tofacitinib in patients with chronic pouchitis multirefractory to biologics. Uzzan M, Nachury M, Amiot A, Peyrin-Biroulet L, Kirchgesner J, Bouhnik Y; GETAID TOFA-POUCH study group. Dig Liver Dis. 2023 Aug;55(8):1158-1160. doi: 10.1016/j.dld.2023.04.028. Epub 2023 May 28. PMID: 37248123
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Introduction

Percutaneous endoscopic gastrostomy (PEG) is the standard method for providing long-term enteral nutrition and medication in patients with insufficient oral intake. However, data on the technical aspects of the procedure, adherence to published guidelines, and the decision-making process of endoscopists remain limited in certain countries.

Aims & Methods

The primary aim of this nationwide study was to assess the current practices among Greek gastroenterologists regarding PEG procedure, covering the entire spectrum of PEG, including initial clinical decision-making, technical aspects, periprocedural management, and long-term patient care. An anonymous web-based survey was distributed to every member of the Hellenic Society of Gastroenterology (HSG), including gastroenterology trainees. Participants electronically completed a 36-item questionnaire divided into five sections:
(1) demographics and professional background,
(2) general questions on PEG placement,
(3) specific procedural aspects,
(4) post-procedural management, and
(5) future perspectives.
Data analysis was performed using Stata statistical software, version 17.0 (StataCorp LLC, College Station, TX, USA).

Results

A total of 127 out of 766 members of the HSG responded (response rate: 16.5%). Regarding PEG placement, 66.7% reported involvement in up to two procedures per week. Multidisciplinary team meetings were rarely implemented, with 82.0% stating they “rarely” or “never” participate in such meetings. Neurological disorders were the leading indication for PEG (67.7%), followed by dementia (18.1%) and obstructive head, neck, or esophageal malignancies (11.8%). The primary indications differed significantly between the public and private sectors (P = 0.007), with neurological disorders being more frequently reported in the private sector (40.5% vs 26.1%), while obstructive tumors were less commonly cited as the main indication for PEG placement (1.6% vs 10.3%). The push-PEG technique in malignancy cases was used by 31.7% of respondents, whereas direct percutaneous endoscopic jejunostomy (D-PEJ) and percutaneous endoscopic gastrojejunostomy (PEG-J) were employed in 11.9% and 37.8%, respectively. Skin antisepsis and use of sterile instruments were consistently reported by 93.7% and 89.0% of the participants, while prophylactic antibiotics and surgical hand washing were routine for 58.3% and 45.7% of them. Regarding the reported incidence of serious adverse events, 17.3% of respondents had encountered at least one case of perforation or peritonitis, 12.6% reported severe bleeding, and 7.9% had experienced a PEG-related death. No statistically significant association was observed between the occurrence of adverse events and the variables age, years post specialization, trainee status, healthcare sector (public vs private), annual number of PEG procedures, or routine use of prophylactic antibiotics. After discharge, structured follow-up programs were reported by 15.1%, while 31.5% indicated that nutritional guidance was provided by a dedicated nutrition department.

Conclusion

This nationwide survey is the first to explore clinical practices related to PEG placement among gastroenterologists in Greece. The findings highlight areas of alignment with international standards, but also reveal important deviations, particularly in multidisciplinary collaboration, infection prevention measures, and postprocedural care. These results provide a valuable foundation for targeted training agendas and quality improvement initiatives.

References

1. Arvanitakis M, Gkolfakis P, Despott EJ, et al. Endoscopic management of enteral tubes in adult patients - Part 1: Definitions and indications. European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2021;53(1):81-92. doi:10.1055/a-1303-7449
2. Bischoff SC, Austin P, Boeykens K, et al. ESPEN practical guideline: Home enteral nutrition. Clin Nutr. 2022;41(2):468-488. doi:10.1016/j.clnu.2021.10.018

Disclosure

Nothing to disclosure.

Introduction

Colorectal cancer (CRC)-driven liver metastasis formation is one of the main drivers of cancer-related deaths. As CRC development has formerly been identified as a disease of elderly people, recent epidemiological data shows an increasing incidence of CRC in people younger than 50 years of age (early-onset colorectal cancer, EOCRC) while less people are being diagnosed with CRC after the age of 50 years (late-onset CRC, LOCRC). Recent studies have identified disparities between these two forms, with early-onset cases often diagnosed at more advanced stages, including elevated risks for recurrence and metastasis formation, including liver metastasis.

Aims & Methods

Here, we have studied how CRC and CRC-dependent liver metastasis develops in an age-dependent manner by using 8-weeks old and 78-weeks old C57BL/6 mice from the same vendor under the same housing conditions. To this end, we used an orthotopic mouse model of CRC-related liver tumor formation, in which colorectal tumor organoids were engrafted in the liver via injection into the portal circulation, solely leading to liver metastasis formation without any primary colon tumor growth. To study age-dependency of primary CRC growth, we injected CRC organoids into the mucosa of the rectum. We further analyzed the molecular mechanisms of disease development, using antibody depletion, genetic mouse and ex vivo tumor models, as well as spatial transcriptomics approaches.

Results

Interestingly, we could demonstrate that young mice exhibit more and larger liver metastases compared to older counterparts, while the formation of primary CRC was unaffected by the age of the host. Liver metastases in old mice display increased necrosis formation which is accompanied by an elevated abundance of different immune cells such as CD8⁺ T cells. Spatial transcriptomics analysis further revealed a distinct anaplerotic metabolic phenotype in liver metastases of young hosts, showing that tumor-surrounding metabolic factors differ between young and old mice, which highlights important metastatic niche dependencies to control tumor growth. Current investigations therefore are directed towards elucidating the factors driving enhanced metastatic development in young hosts and their interactions within the tumor microenvironment, focusing on spatial metabolomics approaches and human cohorts for early-onset CRC.

Conclusion

Our findings demonstrate more aggressive liver metastasis formation in young hosts, as similarly observed in humans, and offer valuable insights into the pathogenesis of early-onset colorectal cancer.