Introduction

Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most common chronic liver disease, with potential progression to metabolic dysfunction-associated steatohepatitis (MASH) and fibrosis. Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have revolutionized obesity treatment, but their role in MASH with fibrosis remains under investigation.

Aims & Methods

This study evaluates the efficacy and safety of GLP-1 RAs in MASH with fibrosis. We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) from PubMed, Embase, and Cochrane. Primary outcomes included histologic improvement in fibrosis without worsening MASH, MASH resolution without worsening fibrosis, and improvement in disease activity score. Secondary outcomes included adverse events (AEs), laboratory, and anthropometric data.

Results

Six RCTs (1,000 patients, mean follow-up: 47 weeks) were included. GLP-1 RAs did not significantly improve fibrosis without worsening MASH (RR 1.35; 95% CI 0.91–2.01; p=0.141; I²=53.5%) or disease activity score (RR 1.33; 95% CI 0.93–1.89; p=0.114; I²=64%). However, they significantly increased MASH resolution without worsening fibrosis (RR 3.50; 95% CI 2.44–5.02; p<0.001; I²=0%). No significant differences were observed in serious AEs. GLP-1 RAs improved laboratory, imaging, glycemic, lipidic, blood pressure, and anthropometric parameters.

Conclusion

GLP-1 RAs appear effective and safe in MASH with fibrosis, particularly in resolving MASH without worsening fibrosis.

Introduction

Intestinal ultrasound is a noninvasive and inexpensive tool to assess disease activity in patients with inflammatory bowel disease, such as Crohn's and ulcerative colitis by monitoring the disease activity in real time.

Aims & Methods

Intestinal ultrasound is a non-invasive, cost-effective imaging tool for routine clinical evaluations. This study examines its role in monitoring Crohn’s disease, comparing it with CT Enterography.
This is a prospective, descriptive, comparative study including patients with crohn's disease aged over 16, between March 2023 and March 2024. Every patient had a colonoscopy, enteroscan, and digestive ultrasonography; the delay between each test was limited to one month by the same operator. Patients with ileal or recto-colic resections or pregnant women were not included. We develope a form to collect clinical, therapeutic, and epidemiological informations as well as the outcomes of CT, colonoscopy, and ultrasounds. Between ultrasound, CT scan and colonoscopy, we asked our patients to choose the most widely accepted para-clinical test. Ultrasonography's sensitivity (Se) and specificity (Sp) were determined, and data from enteroscanner and ultrasound were analyzed, with a focus on the wall's thickness, vascularization, damage extent, and peridigestive environment. The statistical study was carried out using SPSS 21.0 software. Quantitative variables were expressed as medians and qualitative variables as numbers and percentages. The McNemar test and the Wilcoxon test for associated samples were applied. The significance level was set at 0.05.

Results

Forty-nine patients were included, with a male-to-female ratio of 0.53 and a median age of 32 years. US detected digestive thickening in 81.6% of cases, mainly in the terminal ileum. CT Enterography detected thickening in the proximal small bowel and rectum in 2.2% of cases, which US missed. US sensitivity was 84.4%, with specificity of 50%. No significant difference was found between US and CT for thickening detection. Mesenteric infiltration detected by US was similar to CT (Se = 86.5%, Sp = 100%). For adenopathy, Se was 75% (Sp = 97%). US showed a 60% sensitivity for detecting complications, with a significant difference compared to CT (p = 0.002). There was no correlation between thickening on US and ulcers on endoscopy.

Conclusion

Despite limitations in examining the proximal intestine and rectum, intestinal ultrasonography is a sensitive, accessible method for monitoring Crohn’s disease and detecting complications.

Clinical Case Summary

The syndrome of buried lumen-apposing metal stents (LAMS) occurs in 4.7% of cases and is caused by a foreign body reaction characterised by tissue overgrowth embedded in the stent. This complication often requires surgery or "stent-in-stent" endoscopic procedures (1). Stent in a stent safely and effectively recanalises LAMS placed as esophagogastric anastomosis (2), gallbladder drainage (3), and endoscopic ultrasound (EUS)-directed transgastric ERCP (EDGE) (4). We report the first EUS-directed transenteric ERCP (EDEE) case using this approach. In 2023 a patient with Roux-en-Y hepaticojejunostomy (HJ) substenosis and recurrent cholangitis was admitted to our institution. The first attempt to perform an EUS-guided gastrojejunostomy (GJ) as part of EDEE failed; EUS -Hepaticogastrostomy (HGS) was conducted. One month later, a Hot-Axios LAMS (15mm x 15mm) EUS-GJ was placed, and prior 15 mm balloon dilatation, the second part of the EDEE operation was conducted, accessing the surgical HJ with a paediatric colonoscope and placing a Nagi stent (16mm x 20mm) towards the substenosis. The LAMS completely buried itself during the 6-month Nagi removal follow-up, making it impossible to determine its gastric mucosal location. We placed a fully covered self-expandable metal stent (10mm x 8cm) on the HGS for antegrade Nagi stent extraction. Recurrent HJ substenosis and bile duct stones induced cholangitis in 2024. EUS-guided identification and cannulation of the buried LAMS involved passing a 19-G fine needle biopsy needle through the LAMS, advancing a Jagwire deep into the jejunum, and bridging it with a second Hot-Axios LAMS (15mm x 15mm) using a non-cautery enhanced (cold LAMS-in-LAMS) technique.A frontal scope was used to remove bile duct stones before the latest 15 mm balloon was expanded, and a third 15 mm x 10 mm LAMS was placed across the substenotic HJ. EUS-guided management of buried LAMS was safe and effective, with normal liver function tests and clinical outcomes.

References

1) Nayar, M., Leeds, J. S., UK & Ireland LAMS Colloborative, & Oppong, K. (2022). Lumen-apposing metal stents for drainage of pancreatic fluid collections: does timing of removal matter?. Gut, 71(5), 850–853. https://doi.org/10.1136/gutjnl-2021-325812
2) Bazaga Pérez de Rozas, S., Chahal, P., Sánchez-Ocaña, R., García-Alonso, F. J., Carbajo, A. Y., de la Serna-Higuera, C., & Manuel, P. M. (2019). Buried lumen-apposing metal stent (LAMS) in esophagogastric anastomosis: the LAMS-in-LAMS rescue treatment. Endoscopy, 51(6), 600–601. https://doi.org/10.1055/a-0861-99074)
3) Ligresti, D., Cipolletta, F., Amata, M., Cimavilla, M., Traina, M., & Tarantino, I. (2018). Buried lumen-apposing metal stent (LAMS) following endoscopic ultrasound-guided gallbladder drainage: the LAMS-in-LAMS rescue treatment. Endoscopy, 50(8), 822–823. https://doi.org/10.1055/a-0624-2050
4) Honan, B. M., Mulki, R., & Sánchez-Luna, S. A. (2024). Bridging the Buried GATE: LAMS-in-LAMS Rescue Technique for Endoscopic Ultrasound-Directed Transgastric ERCP. ACG case reports journal, 11(9), e01497. https://doi.org/10.14309/crj.0000000000001497