Assessing the effectiveness of texture and color enhancement imaging versus white-light endoscopy in detecting gastrointestinal lesions: A systematic review and meta-analysis

Introduction

Gastrointestinal cancers account for 26% of cancer incidence and 35% of cancer-related deaths globally. Early detection is crucial but often limited by white light endoscopy (WLE), which misses subtle lesions. Texture and color enhancement imaging (TXI), introduced in 2020, enhances texture, brightness, and color, addressing WLE's limitations. This meta-analysis evaluates TXI's effectiveness compared to WLE in gastrointestinal lesion lesion detection.

Methods

A systematic review and meta-analysis were conducted per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Searches of CENTRAL, PubMed, Embase, and Web of Science identified randomized controlled trials and observational studies comparing TXI with WLE. Outcomes included lesion detection rates, color differentiation, and visibility scores. The risk of bias was assessed using the Cochrane ROB 2.0 tool and Newcastle-Ottawa tools, and evidence certainty was evaluated using Grading of Recommendations Assessment, Development, and Evaluation.

Results

Seventeen studies with 16,634 participants were included. TXI significantly improved color differentiation (mean difference: 3.31, 95% confidence interval [CI]: 2.49-4.13), visibility scores (mean difference: 0.50, 95% CI: 0.36-0.64), and lesion detection rates (odds ratio [OR]: 1.84, 95% CI: 1.52-2.22) compared to WLE. Subgroup analyses confirmed TXI's advantages across pharyngeal, esophageal, gastric, and colorectal lesions. TXI also enhanced adenoma detection rates (OR: 1.66, 95% CI: 1.31-2.12) and mean adenoma detection per procedure (mean difference: 0.48, 95% CI: 0.25-0.70).

Conclusion

TXI improves gastriontestinal lesion lesion detection by enhancing visualization and color differentiation, addressing key limitations of WLE. These findings support its integration into routine endoscopy, with further research needed to compare TXI with other modalities and explore its potential in real-time lesion detection.

Endoscopic management of acute cholecystitis in high-risk surgical patients: A comprehensive review article

Acute cholecystitis is frequently encountered in daily clinical practice, and early cholecystectomy is the standard therapy. In high-risk surgical patients, such as those with advanced age, deteriorated performance status, or underlying diseases, conservative treatment is typically preferred to manage acute cholecystitis. However, in patients with a disease that is refractory to conservative treatment, drainage procedures are necessary to control the infection. At present, there are three basic approaches for gallbladder drainage: percutaneous transhepatic gallbladder drainage, endoscopic transpapillary gallbladder drainage, and endoscopic ultrasound gallbladder drainage. Each of these methods has advantages and disadvantages. Therefore, the appropriate treatment method is determined on a case-by-case basis, and no consistent strategy for gallbladder drainage has been established. This review aimed to summarize the characteristics of each drainage method and compare the clinical outcomes of the three procedures for acute cholecystitis in high-risk surgical patients.

Investigation of the actual implementation of "post-sedation discharge briteria" and "time-out" immediately before procedure in endoscopy: A nationwide survey study in Japan

OBJECTIVES

Post-sedation discharge criteria for outpatient endoscopy and time-out procedures immediately before endoscopic examinations are important for ensuring patient safety. This study used a web-based questionnaire to survey the implementation status and current situation of these practices in Japan in 2024.

METHODS

A self-administered questionnaire was conducted from December 2023 to January 2024 using Google Forms. Participants were primarily from facilities involved in endoscopy study groups and readers of an endoscopy-specific e-newsletter. Additionally, medical staff from endoscopic centers across Japan were invited to participate in collaboration with the Japan Gastroenterological Endoscopy Technicians Society.

RESULTS

A total of 1,495 valid responses (medical staff: 1197 [80%]; doctors: 298) were collected from 1168 facilities, after excluding duplicate responses. Among the participating facilities, 58% were general hospitals, 21% were clinics or health check-up centers, and 9% were university hospitals or national cancer centers. Post-sedation discharge criteria were implemented in 58% of facilities for esophagogastroduodenoscopy and 56% for colonoscopy, with the post-sedation recovery score used as the criterion in about half of these cases. Time-out procedures were implemented in 57% of the facilities for both esophagogastroduodenoscopy and colonoscopy. Items confirmed during time-out in more than half of the facilities included: patient's name, details of antithrombotic drugs, content of examination, drug allergies, underlying disease, date of birth, consent form, age, procedure start time, and patient's identification number.

CONCLUSION

The implementation rate of post-sedation discharge criteria and time-out procedures was found to be close to 60%, reflecting the real-world situation in Japan in 2024.

Optimal timing of precut sphincterotomy to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis in difficult biliary cannulation: A retrospective study

Objectives

Precut sphincterotomy is often performed when bile duct cannulation is difficult; however, the former has a higher risk of complications than conventional methods. Early precut reduces the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). This study aimed to determine the appropriate timing for precut sphincterotomy to minimize the incidence of PEP.

Methods

This retrospective study analyzed 320 patients who underwent precut sphincterotomy during their first endoscopic retrograde cholangiopancreatography at a single center. The optimal precut timing was identified using receiver operating characteristic analysis. Patients were divided into an optimized precut group (≤12 min, n = 198) and a delayed group (>12 min, n = 122). The incidence and risk factors of PEP were evaluated using multivariate analyses.

Results

Receiver operating characteristic analysis identified 12.5 min as the optimal cutoff for transitioning to precut sphincterotomy (area under the curve, 0.613; sensitivity, 61.5%; specificity, 63.9%). The incidence of PEP was significantly lower in the optimized precut group than in the delayed precut group (5.1% vs. 13.1%, p = 0.02). Multivariate analysis identified delayed precut timing (odds ratio [OR], 3.134; p = 0.04) and the absence of endoscopic pancreatic stenting (OR, 0.284; p = 0.01) as independent risk factors for PEP.

Conclusion

Precut sphincterotomy within 12.5 min of a cannulation attempt reduces the risk of PEP while maintaining procedural safety. Additionally, endoscopic pancreatic stenting can reduce PEP, even in precut scenarios.

Updated evidence on epidemiology, diagnosis, and treatment for colonic diverticular bleeding

Since 2020, multiple large-scale studies (CODE BLUE-J) in Japan have accelerated the accumulation of evidence on colonic diverticular bleeding (CDB). This review summarizes the latest findings regarding CDB epidemiology and endoscopic hemostasis. Recent data show that CDB has become the most common cause of lower gastrointestinal bleeding in Japan, driven by an aging population and the increased use of antithrombotic medications. Although 70%-90% of patients achieve spontaneous hemostasis, rebleeding occurs in up to 35% of cases within 1 year. Despite an overall mortality rate of < 1%, patients with CDB can present with hypovolemic shock and may require urgent intervention. There are no effective pharmacological treatments for controlling CDB. Therefore, endoscopic therapy plays a crucial role in its management. Based on available evidence, both clipping and endoscopic band ligation are considered effective initial treatments. Recent studies indicate that direct clipping reduces early rebleeding compared with indirect clipping, while endoscopic band ligation achieves lower rebleeding rates (13%-15%) than clipping. The choice between direct clipping and endoscopic band ligation depends on the diverticulum location and the presence of active bleeding. Newer techniques, such as over-the-scope clip and self-assembling peptide application, have shown potential, but require further study. The detection of the bleeding source remains challenging because accurate identification is essential for successful hemostasis. Additional research is needed to refine the endoscopic diagnostic and therapeutic techniques, prevent rebleeding, and improve patient outcomes.

The Current Landscape of Endoscopic Submucosal Training in the United States

PURPOSE OF REVIEW

Endoscopic submucosal dissection (ESD) has been found to increase en bloc and R0 resection as well as decrease risk of recurrence. However, despite literature supporting the benefits of endoscopic submucosal dissection, adoption of ESD in the United States has been challenging, driven by factors including requirement for specialized training as well as limitations in training availability.

RECENT FINDINGS

Many devices have been developed to improve ease and therefore adoption for the procedure, with advancements in stability, resection as well as closure of the mucosal defect following resection. While the Japanese model of training in ESD centers around the Master-Apprentice model, this is scarce in the United States. Most US endoscopists therefore must follow other paths to learn and become proficient at ESD. There has been a rapid expansion in literature on ESD, fellowship programs, opportunities for case observation, and significant evolution in ex vivo training models that can assist an endoscopist in receiving training in ESD. Currently, there are three main ways of learning to perform ESD in the United States: 1. Third space endoscopy fellowship; 2. Master-apprentice model; 3. Utilization of live courses and proctored procedures. ESD is the optimal method to ensure en bloc resection of large mucosal neoplasms of the gastrointestinal tract. While several barriers hinder adoption of ESD in the United States, there has been significant development both in procedural and training aspects. Further research and discussions are needed to determine criteria for credentialing and proficiency in ESD.

Colonic strictures in Crohn's disease: a non-surgical survival

BACKGROUND

Colonic stenosis in Crohn's disease (CD) is uncommon, and data on surgery-free survival are limited. This study aimed to determine surgery-free survival rates and identify associated factors.

PATIENTS AND METHODS

A retrospective study was conducted from 2003 to 2022, including patients with CD complicated by colonic stenosis. Patients with uncertain diagnoses or follow-up periods of less than six months were excluded.

RESULTS

Fifty-six patients were included (median age 44 years [range 14-65], male-to-female ratio = 0.93). Surgery-free survival rates were 58.9% at 6 months, 43.7% at 2 years, and 31.7% at 5 years, with an average surgery-free survival of 46.7 months. Univariate analysis showed that joint manifestations (p = 0.01), corticosteroids (p = 0.02), anti-TNF alpha (p = 0.02), salicylates (p = 0.02), and azathioprine (p = 0.01) increased surgery-free survival. Complications such as collections or internal fistulas (p = 0.03), parietal ulceration on imaging (p = 0.01), and acute intestinal obstruction (p = 0.01) were associated with reduced surgery-free survival. In multivariate analysis, biologic therapy was the only independent protective factor against surgery (p = 0.001, OR = 0.19).

CONCLUSION

The early introduction of biologic therapy is crucial for increasing surgery-free survival in patients with colonic stenosis in CD, given the limited effectiveness of conventional treatments.

Endoscopic Gallbladder Drainage EUS LAMS vs. ERCP Trans-papillary Drainage

PURPOSE OF REVIEW

In this review, we discuss the role of endoscopic gallbladder drainage for acute cholecystitis in non-surgical candidates, describe technical aspects, clinical outcomes, and elaborate on considerations when determining which approach to adopt for a given patient.

RECENT FINDINGS

Cholecystectomy remains the criterion standard for management of acute cholecystitis in patients who can safely undergo surgery. For non-surgical candidates, percutaneous cholecystostomy (PTC-GBD) has been the traditional strategy to drain and decompress the gallbladder. Advances in endoscopy have further expanded the nonsurgical interventions and approaches to cholecystitis. Both endoscopic transpapillary gallbladder drainage (ET-GBD) and endoscopic ultrasound guided gallbladder drainage (EUS-GBD) have become acceptable alternatives to PTC-GBD, with growing literature supporting their efficacy, safety and improved patient quality of life when compared to a percutaneous approach. Choosing the appropriate endoscopic technique for gallbladder drainage should be tailored to each patient, keeping in view the specific clinical scenarios, endoscopist preference and following a multi-disciplinary approach.

Third space endoscopy pulmonary complications and chylothorax post peroral endoscopic myotomy

Third-space endoscopy (TSE) has emerged as an effective treatment modality for various gastrointestinal motility diseases and gastrointestinal tumors. TSE is based on the concept of working in the submucosa using a mucosal flap valve technique, which is the underlying premise for all TSE procedures; thus, some complications are shared across the spectrum of TSE procedures. Despite the high safety profiles of most TSE procedures, studies have reported various adverse events, including insufflation-related complications, bleeding, perforation, and infection. Although the occurrence rate of those complications is not very high, they sometimes result in critical conditions. No reports of chylous effusion following TSE procedures, particularly per-oral endoscopic myotomy, have been documented previously. We are presenting the first reported case of chylous pleural effusion after per-oral endoscopic myotomy. Additionally, we aim to present a comprehensive overview, discuss the existing data, and provide insights into pulmonary post-endoscopic complications in light of recent advancements in endoscopic procedures, especially TSE.

Management of Esophageal Strictures

In this article, we review current state-of-the art techniques for the endoscopic management of esophageal strictures including balloon dilation, bougie dilation, stents, and steroid injection. We discuss the approach to stricture management based on specific disease states including reflux, eosinophilic esophagitis, caustic injuries, malignancy, and dermatologic conditions.

Efficacy of Endoscopic Sutured Gastroplasty on Diabetes Mellitus Type 2-A Systematic Review

INTRODUCTION

Endoscopic sutured gastroplasty (ESG) is one of the currently available endoscopic techniques that mimics bariatric surgery. Although the efficacy of ESG on weight loss has repeatedly been demonstrated, its effect on diabetes mellitus type 2 (T2DM) related outcomes is not yet fully clear.

METHODS

We conducted a systematic review summarising the efficacy of ESG on T2DM. Therefore, PubMed, Embase and Cochrane library were searched for studies evaluating the effect of ESG on T2DM. Both prospective and retrospective studies, published in the English language, were included. Two reviewers independently screened all studies. The primary objectives were T2DM remission rate, decrease in glucose-lowering medication and decrease in HbA1c.

RESULTS

A total of 16 studies including 760 patients with (pre)diabetes were included. Overall, T2DM-related outcomes after ESG improved in 303 of 599 patients (50.6%) (including tapering dose of insulin and/or improvement of HbA1c/fasting glucose). Remission rates of T2DM were reported in 6/11 studies and seen in 89 of 155 (57.0%) patients after 6-36 months.

CONCLUSION

This systematic review on the efficacy of ESG on T2DM suggests that ESG is able to improve diabetes-related outcomes in approximately half of treated patients, with T2DM remission rates in more than half of them.

Comparison between interrupted closure technique and traditional closure technique in endoscopic full-thickness resection for treating gastric subepithelial lesions

BACKGROUND

Gastric subepithelial lesions (SELs) are elevated lesions originating from the muscularis mucosa, submucosa, or muscularis propria, and may also include extraluminal lesions. For small SELs (less than 5 cm), complete endoscopic excision is the preferred treatment. Endoscopic full-thickness resection (EFTR) has proven to be an effective approach.

AIM

To evaluate the efficacy of the interrupted closure technique compared to the traditional closure technique in EFTR for gastric SELs.

METHODS

This single-center, prospective, randomized controlled trial was conducted at a tertiary hospital from September 2023 to September 2024. A total of 90 patients who underwent EFTR for gastric SELs were randomly allocated to either the interrupted closure group (n = 44) or the traditional closure group (n = 46).

RESULTS

All patients had complete resection and wound closure without any severe postoperative complications. The incidence of intraoperative gas-related complications was significantly lower in the interrupted closure group than in the traditional closure group (2.27% vs 26.09%, P = 0.001), demonstrating interrupted closure technique can reduce the incidence of gas-related issues. Statistical analysis revealed that the incidence of postoperative infection was significantly lower in the experimental group than in the control group (15.91% vs 41.30%, P = 0.008). Additionally, the median duration of antibiotic use was lower in the experimental group (3.5 days vs 5 days, P = 0.013). Abdominal pain levels on postoperative days 1 and 4 were also lower in the experimental group compared to the control group (P < 0.001).

CONCLUSION

The interrupted closure technique in EFTR for treating gastric SELs is safe and effective, reducing the incidence of intraoperative gas complications and postoperative infections.

Impact of enhanced bowel preparation on complications and prognosis following colonoscopic polypectomy

BACKGROUND

Colonoscopic polypectomy is a crucial procedure for the prevention and treatment of colorectal cancer, with its success and safety largely dependent on the quality of bowel preparation. Currently, polyethylene glycol electrolyte solution remains the standard method for bowel preparation, but its use may cause patient discomfort and incomplete cleansing.

AIM

To evaluate impact of enhanced and conventional bowel preparation protocols on the outcomes of colonoscopic polypectomy.

METHODS

This retrospective cohort study collected data from 130 patients who underwent colonoscopic polypectomy between March 2023 and June 2024. Patients were divided into the conventional bowel preparation group (n = 65) and enhanced bowel preparation group (n = 65). Primary outcome measures included Boston Bowel Preparation Scale (BBPS) scores, procedure-related parameters, complication rates, and prognosis. Statistical analysis was performed using SPSS version 25.0, with P < 0.05 indicating statistical significance.

RESULTS

The enhanced group demonstrated significant advantages over the conventional group, with higher BBPS total scores (4.2 ± 0.7 vs 3.1 ± 0.8, P < 0.001), higher one-time complete resection rates (95.4% vs 83.1%, P = 0.01), shorter operative times (23.1 ± 4.8 vs 25.4 ± 5.2 min, P = 0.03), and lesser intraoperative blood loss (18.2 ± 4.5 vs 20.3 ± 5.1 mL, P = 0.04). Total complication rates were significantly lower (5.9% vs 16.9%, P = 0.05), particularly for bleeding (1.5% vs 16.9%, P = 0.01) and infection (1.5% vs 7.7%, P = 0.04). The enhanced group also showed lower 6-month recurrence rates (3.1% vs 10.8%, P = 0.05) and higher patient satisfaction (87.7% vs 76.9%, P = 0.04) than did the conventional group.

CONCLUSION

The enhanced bowel preparation protocol demonstrates significant advantages, particularly in improving surgical outcomes, reducing complications, and increasing patient satisfaction, underscoring its importance of its application during colonoscopic polypectomy.

Quality of life and outcomes in patients undergoing endoscopic papillectomy vs surgical treatment for duodenal papillary adenomas

BACKGROUND

Endoscopic papillectomy (EP) via endoscopic retrograde cholangiopancreatography has emerged as a less invasive alternative to surgery for duodenal papillary adenomas (DPAs), which is traditionally associated with notable postoperative risks.

AIM

To compare quality of life (QoL) and outcomes between DPA patients undergoing EP vs surgical resection, and to assess the influencing factors of QoL and complications.

METHODS

We conducted a retrospective, single-center analysis involving patients treated for DPA at the Drum Tower Hospital of Nanjing University Medical School from 2011 to 2023. The participants completed post-discharge telephone surveys using the 12-item short form survey to assess mental (MCS) and physical component summary (PCS) scores, with norm-based scoring where ≥ 50 denotes normal. Multivariate regression analysis adjusted for confounding variables was used to compare QoL scores.

RESULTS

Compared with EP patients, surgically treated patients had significantly lower PCS [median: 53.0, interquartile range (IQR): 46.0-55.1 vs 54.2, IQR: 51.7-55.9, P = 0.008] and MCS scores (median: 48.6, IQR: 41.8-56.0 vs 55.9, IQR: 51.7-60.7, P < 0.001). These disparities persisted even after adjustments for demographic and medical factors. Long-term follow-up of the EP group revealed that abdominal pain and poor sleep were factors negatively impacting PCS scores, whereas postoperative pancreatitis and hypertension were associated with lower MCS scores.

CONCLUSION

EP has emerged as a QoL-preserving alternative for patients with DPA, conditional upon ensuring equivalent efficacy and safety. QoL outcomes should be considered when choosing interventions for this patient population.

Temporal changes in computed tomography findings of a persimmon bezoar: A case report

BACKGROUND

Gastric bezoars are masses of indigestible material that accumulate in the stomach, causing nausea, abdominal pain, and vomiting. Persimmon bezoars (diospyrobezoars), which comprise tannins and fibers from persimmons, are relatively rare but may cause significant gastric complications, including gastric outlet obstruction or ileus. Although computed tomography (CT) is a useful imaging tool, diagnosing bezoars can be challenging because their density is similar to that of food debris and gastric content.

CASE SUMMARY

Here, we report the case of a 72-year-old woman with a persimmon bezoar that was diagnosed using serial CT imaging and confirmed by endoscopy. CT performed over several months revealed changes in the internal structure and density of the bezoar, suggesting progressive hardening. The patient had a history of a partial gastrectomy and excessive persimmon consumption, both of which are risk factors for bezoar formation. Endoscopic fragmentation of the bezoar successfully resolved symptoms.

CONCLUSION

Gastric bezoars, particularly persimmon bezoars, present diagnostic challenges because of their variable imaging characteristics. Serial CT can document temporal changes in bezoar density, potentially reflecting changes in hardness. Early diagnosis and endoscopic treatment are essential for effective management, particularly in patients with predisposing factors. This case underscores the importance of considering bezoars in the differential diagnosis of gastric masses, and highlights the value of CT for monitoring changes in bezoar characteristics over time.

Enhancing laparoscopic inguinal hernia repair with three-dimensional computed tomography reconstruction

Zhang et al highlighted the importance of three-dimensional computed tomography reconstruction and myopectineal orifice measurement in laparoscopic inguinal hernia repair. Their findings indicated that preoperative three-dimensional computed tomography provides precise anatomical mapping, allowing surgeons to optimize mesh selection and reduce recurrence rates. Recent studies have corroborated these results, demonstrating that a personalized mesh size based on myopectineal orifice dimensions leads to superior patient outcomes. This article discusses the clinical significance of these advancements in hernia surgery, and emphasises their impact on improving precision, reducing complications, and optimizing surgical planning.

Modern endoscopist’s toolbox: Innovations in foreign body removal

Foreign body ingestion is a common gastrointestinal emergency, particularly in children, who account for 80% of cases. While most ingested objects pass spontaneously, around 20% require medical intervention. In adults, incidents often occur accidentally during meals, leading to impactions, especially in individuals with underlying esophageal conditions. Endoscopy remains the gold standard for foreign body retrieval, with a success rate exceeding 95%. The type, shape, and location of the foreign body determine the clinical presentation and management approach. Sharp objects, batteries, and large items pose the highest risk of complications, including perforation, obstruction, and chemical injury. Prompt endoscopic removal is guided by established protocols, with emergent intervention required for complete esophageal obstruction and high-risk objects. Various retrieval devices, including forceps, snares, baskets, and overtubes, are used based on the nature of the foreign body. Technological advancements, such as artificial intelligence-assisted imaging and endoscopic ultrasound, are improving diagnostic precision and procedural outcomes. Despite these advances, foreign body ingestion can still lead to severe complications if not managed in a timely manner. Public awareness, preventive measures, and rapid medical response are essential in reducing morbidity and mortality associated with foreign body ingestion.

Is endoscopic retrograde cholangiopancreatography safe for centenarians?

This letter aims to discuss the article, published in the recent issue of the World Journal of Gastrointestinal Endoscopy 2025. Endoscopic retrograde cholangiopancreatography (ERCP) is widely acknowledged as an effective procedure for managing biliary obstruction. However, its use in very elderly patients, particularly centenarians, presents unique challenges related to both safety and efficacy. In this report, we share our experience with three centenarian patients who underwent ERCP for biliary obstruction in our unit. Remarkably, all patients had favorable outcomes, and no significant adverse events were observed.

Sedation in endoscopy: Current practices and future innovations

Sedation practices in gastrointestinal endoscopy have evolved considerably, driven by patient demand for comfort and the need to minimize cardiopulmonary complications. Recent guidelines emphasize personalized sedation strategies, risk assessment, and vigilant hemodynamic monitoring to ensure that sedation depth aligns with each patient’s comorbidities and procedural requirements. Within this landscape, the trial by Luo et al highlights the value of adding etomidate to propofol target-controlled infusion, demonstrating significantly reduced hypotension, faster induction, and fewer respiratory complications in typical American Society of Anesthesiologists I-III candidates. These findings align with broader recommendations from both European and American societies advocating sedation regimens that preserve stable circulation. Etomidate’s favorable hemodynamic profile, coupled with propofol’s reliability, suggests potential applications in advanced endoscopic interventions such as endoscopic retrograde cholangiopancreatography, interventional endoscopic ultrasound, and endoscopic submucosal dissection, where deeper or more sustained sedation is often required. Remimazolam, a novel short-acting benzodiazepine, has similarly been associated with reduced cardiovascular depression and faster recovery, particularly in high-risk populations, although direct comparisons between etomidate-propofol and remimazolam-based regimens remain limited. Further investigations into these sedation strategies in higher-risk cohorts, as well as complex therapeutic endoscopy, will likely inform more nuanced, patient-specific protocols aimed at maximizing both safety and procedural efficiency.

Artificial intelligence and endoanal ultrasound: pioneering automated differentiation of benign anal and sphincter lesions

BACKGROUND

Anal injuries, such as lacerations and fissures, are challenging to diagnose because of their anatomical complexity. Endoanal ultrasound (EAUS) has proven to be a reliable tool for detailed visualization of anal structures but relies on expert interpretation. Artificial intelligence (AI) may offer a solution for more accurate and consistent diagnoses. This study aims to develop and test a convolutional neural network (CNN)-based algorithm for automatic classification of fissures and anal lacerations (internal and external) on EUAS.

METHODS

A single-center retrospective study analyzed 238 EUAS radial probe exams (April 2022-January 2024), categorizing 4528 frames into fissures (516), external lacerations (2174), and internal lacerations (1838), following validation by three experts. Data was split 80% for training and 20% for testing. Performance metrics included sensitivity, specificity, and accuracy.

RESULTS

For external lacerations, the CNN achieved 82.5% sensitivity, 93.5% specificity, and 88.2% accuracy. For internal lacerations, achieved 91.7% sensitivity, 85.9% specificity, and 88.2% accuracy. For anal fissures, achieved 100% sensitivity, specificity, and accuracy.

CONCLUSION

This first EUAS AI-assisted model for differentiating benign anal injuries demonstrates excellent diagnostic performance. It highlights AI's potential to improve accuracy, reduce reliance on expertise, and support broader clinical adoption. While currently limited by small dataset and single-center scope, this work represents a significant step towards integrating AI in proctology.

Long-Term Efficacy of Repeated Endoscopic Incision Combined with Triamcinolone Injection in Patients with Recurrent Benign Esophageal Stricture

BACKGROUND AND AIMS

Endoscopic incision (EI) combined with triamcinolone (TAA) injection has emerged as an effective method for treating benign esophageal stricture (BES). However, a single EI and TAA injection seems to be insufficient for long-term relief of BES in some patients, especially those with recurrent BES. Here, we aimed to investigate the long-term efficacy and safety of repeated EIs and TAA injections in patients with recurrent BES.

METHODS

Patients with recurrent BES who previously underwent endoscopic dilation or EI were enrolled in this retrospective study. All patients underwent multiple EIs and TAA injections. Patients were followed for at least 12 months. The primary outcome was the rate of re-stricture at 6 months after repeated EIs and TAA injections. The secondary outcomes included the symptom relief rate, the change in Stooler's dysphagia score (0, normal swallowing; 1, semidry food intake only; 2, soft food intake only; 3, fluid only; and 4, no oral intake) and body mass index (BMI) at 6 months, and overall adverse events (AEs). The risk factors for 6-month re-stricture were identified using logistic regression analysis.

RESULTS

A total of 73 patients were enrolled in this study, including 30 (41.1%) with esophagogastric anastomotic strictures, 15 (20.5%) with caustic injury-related strictures, 14 (19.2%) who developed strictures after ESD, 5 (6.8%) with esophagojejunal anastomotic strictures and 9 (12.3%) with other types of strictures. A total of 264 EIs and TAA injections were performed, with 3 (IQR: 2, 5) treatments for each patient. The 6-month re-stricture rate was 53.4%, and the 2-month, 3-month, and 12-month re-stricture rates were 43.8%, 48.0%, and 54.8%, respectively. The 2-month, 3-month, 6-month, and 12-month dysphagia relief rates were 75.3%, 65.8%, 56.2%, and 54.8%, respectively. At 6 months after treatments, the median Stooler's dysphagia score had decreased from 4 (IQR: 4, 4) to 2 (IQR: 0, 4) (P < 0.001), and the median BMI had increased from 19.6 (IQR: 16.9, 21.8) kg/m2 to 20.8 (IQR: 17.4, 22.6) kg/m2 (P < 0.001). Bile reflux (OR 9.90, 95% CI: 0.99-98.43) and the number of EIs (OR 1.68, 95% CI: 1.17-2.41) were independently associated with 6-month re-stricture after repeated EIs and TAA injections. Four EI-related perforations were successfully treated with a covered metal stent (n = 3) and rescue surgery (n = 1).

CONCLUSIONS

Repeated EIs and TAA injections were effective and reasonably safe in managing recurrent BES. However, the long-term efficacy remains suboptimal, thus further investigations are needed.

Lumen Apposing Metal Stents for Gastrojejunal Anastomotic Stricture Following Metabolic Bariatric Surgery

BACKGROUND

The standard of care for gastrojejunal anastomotic stricture following metabolic bariatric bypass surgery is endoscopic balloon dilatation, with revisional surgery as a last line option. The use of lumen-apposing metal stents is expanding to include many gastrointestinal benign and malignant causes in selected cases. They may provide an additional treatment option for post-bypass strictures.

METHODS

A single centre, retrospective outcomes analysis was performed over a 3-year period of patients with gastrojejunal anastomotic stricture following metabolic bariatric surgery that was treated with a lumen-apposing metal stent. Primary outcomes assessed were clinical success and perforation. Multiple secondary outcomes were assessed regarding safety and endoscopy use.

RESULTS

Of 88 patients that had lumen-apposing metal stents placed, 20 satisfied selection criteria. Eleven patients (55%) had at least one balloon dilatation prior to stent placement. All patients achieved clinical success 20 (100%) with zero perforations. Technical success was achieved in 19 patients (95%). There were four (20%) recurrent strictures, two stent migrations (10%) (with no associated complication), and one in-stent food bolus obstruction (5%). One patient ultimately required surgical revision (5%). Three patients had endoscopy within 30 days of stent removal (15%), and five patients required unplanned endoscopy with the stent in situ (25%).

CONCLUSION

Lumen-apposing metal stents within our study show potential as another treatment option for gastrojejunal anastomotic stricture following gastric bypass.

Gastrointestinal symptoms in the journey of pancreatic cancer patients

INTRODUCTION

Pancreatic ductal adenocarcinoma (PDAC) is a lethal malignancy frequently arising with nonspecific and overlooked gastrointestinal symptoms. Gastroenterologists are typically the first specialists to encounter these patients, positioning them to play a pivotal role not only in early diagnosis, but also in the ongoing management of the disease's complex symptom burden.

AREAS COVERED

This review explored gastrointestinal symptoms in patients with PDAC (ranging from pain and diarrhea to anorexia, jaundice, and nausea) and outlined both tumor- and treatment-related causes. A literature review based on non-systematic PubMed search updated to April 2025 was conducted to summarize current diagnostic strategies, medical, endoscopic therapies, and multidisciplinary management approaches. In addition, we present original data from a single-center cohort, suggesting that the involvement of gastroenterologists leads to more comprehensive management of gastrointestinal symptom control and supportive care.

EXPERT OPINION

Collaboration among specialists is essential for optimizing patient outcomes in the multidisciplinary management of PDAC. Gastroenterologists' 'stewardship' significantly contributes to prompt diagnosis, symptom control, quality of life preservation, and prognosis. Future priorities should focus on strengthening integration within care pathways, fostering interdisciplinary coordination, and implementing shared clinical tools to enhance comprehensive patient care. A well-structured team-based approach is key to advancing holistic PDAC management.

Breaking the cycle: Psychological and social dimensions of pediatric functional gastrointestinal disorders

BACKGROUND

Functional gastrointestinal disorders (FGIDs) in children present with chronic symptoms like abdominal pain, diarrhea, and constipation without identifiable structural abnormalities. These disorders are closely linked to gut-brain axis dysfunction, altered gut microbiota, and psychosocial stress, leading to psychiatric comorbidities such as anxiety, depression, and behavioral issues. Understanding this bidirectional relationship is crucial for developing effective, holistic management strategies that address physical and mental health.

AIM

To examine the psychiatric impacts of FGIDs in children, focusing on anxiety and depression and their association with other neurodevelopmental disorders of childhood, such as attention-deficit/hyperactivity disorder, emphasizing the role of the gut-brain axis, emotional dysregulation, and psychosocial stress. Key mechanisms explored include neurotransmitter dysregulation, microbiota imbalance, central sensitization, heightening stress reactivity, emotional dysregulation, and symptom perception. The review also evaluates the role of family dynamics and coping strategies in exacerbating FGID symptoms and contributing to psychiatric conditions.

METHODS

A narrative review was conducted using 328 studies sourced from PubMed, Scopus, and Google Scholar, covering research published over the past 20 years. Inclusion criteria focused on studies examining FGID diagnosis, gut-brain mechanisms, psychiatric comorbidities, and psychosocial factors in pediatric populations. FGIDs commonly affecting children, including functional constipation, abdominal pain, irritable bowel syndrome, gastroesophageal reflux, and cyclic vomiting syndrome, were analyzed concerning their psychological impacts.

RESULTS

The review highlights a strong connection between FGIDs and psychiatric symptoms, mediated by gut-brain axis dysfunction, dysregulated microbiota, and central sensitization. These physiological disruptions increase children's vulnerability to anxiety and depression, while psychosocial factors - such as chronic stress, early-life trauma, maladaptive family dynamics, and ineffective coping strategies - intensify the cycle of gastrointestinal and emotional distress.

CONCLUSION

Effective management of FGIDs requires a biopsychosocial approach integrating medical, psychological, and dietary interventions. Parental education, early intervention, and multidisciplinary care coordination are critical in mitigating long-term psychological impacts and improving both gastrointestinal and mental health outcomes in children with FGIDs.

Application of artificial intelligence-assisted confocal laser endomicroscopy in gastrointestinal imaging analysis

Confocal laser endomicroscopy (CLE) has become an indispensable tool in the diagnosis and detection of gastrointestinal (GI) diseases due to its high-resolution and high-contrast imaging capabilities. However, the early-stage imaging changes of gastrointestinal disorders are often subtle, and traditional medical image analysis methods rely heavily on manual interpretation, which is time-consuming, subject to observer variability, and inefficient for accurate lesion identification across large-scale image datasets. With the introduction of artificial intelligence (AI) technologies, AI-driven CLE image analysis systems can automatically extract pathological features and have demonstrated significant clinical value in lesion recognition, classification diagnosis, and malignancy prediction of GI diseases. These systems greatly enhance diagnostic efficiency and early detection capabilities. This review summarizes the applications of AI-assisted CLE in GI diseases, analyzes the limitations of current technologies, and explores future research directions. It is expected that the deep integration of AI and confocal imaging technologies will provide strong support for precision diagnosis and personalized treatment in the field of gastrointestinal disorders.

Rectal diclofenac versus indomethacin for prevention of post-ERCP pancreatitis (DIPPP): a multicentre, double-blind, randomised, controlled trial

BACKGROUND

Recent meta-analyses suggested diclofenac may be superior to indomethacin in preventing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). The aim of our study was to compare the efficacy of 100 mg rectal indomethacin versus diclofenac on PEP incidences.

DESIGN

This multicentre, double-blinded, randomised controlled trial was conducted in nine tertiary centres in China. Patients with low and high risk for PEP and native papilla were randomly allocated (1:1) to receive 100 mg diclofenac or 100 mg indomethacin rectally before ERCP. The primary outcome was the occurrence of PEP defined by the Cotton consensus. The intention-to-treat principle was conducted for the analysis.

RESULTS

The trial was terminated early for futility after the predetermined first interim analysis. Between June 2023 and May 2024, 1204 patients were randomised into the diclofenac group (n=600) or indomethacin group (n=604). Baseline characteristics were balanced. The primary outcome occurred in 53 patients (8.8%) of 600 patients allocated to the diclofenac group and 37 patients (6.1%) of 604 patients allocated to the indomethacin group (relative risk 1.44; 95% CI 0.96 to 2.16, p=0.074). PEP occurred in 35 (14.2%) of 247 high-risk patients in the diclofenac group and 26 (9.8%) of 266 high-risk patients in the indomethacin group (p=0.124). PEP incidences were also comparable in low-risk patients between the two groups (18/353 (5.1%) vs 11/338 (3.3%), p=0.227). Other ERCP-related complications did not differ between the two groups.

CONCLUSION

Pre-procedure 100 mg rectal diclofenac was not superior to the same dose of rectal indomethacin regarding preventing PEP. These findings supported current clinical practice guidelines of 100 mg indomethacin or diclofenac for PEP prophylaxis in patients without contraindications.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov (NCT05947461).

Multicentre randomised controlled trial of a self-assembling haemostatic gel to prevent delayed bleeding following endoscopic mucosal resection (PURPLE Trial)

BACKGROUND

Prophylactic application of a haemostatic gel to the resection field may be an easy way to prevent delayed bleeding, a frequent complication after endoscopic mucosal resection (EMR).

OBJECTIVE

We aimed to evaluate if the prophylactic application of a haemostatic gel to the resection field directly after EMR can reduce the rate of clinically significant delayed bleeding events.

DESIGN

We conducted a prospective randomised trial of patients undergoing hot-snare EMR of flat lesions in the duodenum (≥10 mm) and colorectum (≥20 mm) at 15 German centres. Prophylactic clip closure was not allowed, but selective clipping or coagulation could be used prior to randomisation to treat intraprocedural bleeding or for prophylactic closure of visible vessels. Patients were randomised to haemostatic gel application or no prophylaxis. The primary endpoint was delayed bleeding within 30 days.

RESULTS

The trial was stopped early due to futility after an interim analysis. The primary endpoint was analysed in 232 patients (208 colorectal, 26 duodenal). Both groups were comparable in age, sex, comorbidities and lesion characteristics. Preventive measures, such as selective clipping or coagulation, were applied prior to randomisation in 51.9% of cases, with no difference between groups. Delayed bleeding occurred in 14 cases (11.7%; 95% CI 7.1% to 18.6%) after Purastat and in 7 cases (6.3%; 95% CI 3.1% to 12.3%) in the control group (p=0.227), with no difference between colorectal and duodenal subgroups.

CONCLUSION

The application of a haemostatic gel following EMR of large flat lesions in the duodenum and colorectum does not reduce the rate of delayed bleeding.

Metastatic synovial sarcoma masquerading as primary neuroendocrine tumor of pancreas: a diagnostic conundrum

Metastatic sarcomas to the pancreas are extremely rare, with poor survival rates. Therefore, rapid diagnosis and differentiation from primary malignant tumors of pancreas thereby guiding the treatment is indispensable. Endoscopic ultrasound-guided fine needle biopsy (EUS-FNB) is the current diagnostic modality of choice for pancreatic tumor sampling with promising results. Definitive pathologic diagnosis requires adequate tissue for performing ancillary studies. We present a rare case of metastatic synovial sarcoma in the pancreas in an elderly male to endorse the utility of EUS-FNB with imprint cytology as a rapid and effective diagnostic tool.

Revascularization of chronic occluded celiac artery for gastroduodenal coil embolization in massive upper gastrointestinal bleed

Upper gastrointestinal bleeding is a serious condition often linked to peptic ulcer disease, contributing to significant morbidity and mortality. A 78-year-old male presented with upper gastrointestinal bleeding that required blood product transfusions despite multiple endoscopic interventions. Although embolization or surgical ligation of the gastroduodenal artery was considered, angiography revealed celiac trunk occlusion, which would increase the risk of hepatic ischemia. Recanalization and stenting of the celiac trunk was performed, facilitating successful embolization of the gastroduodenal artery. This case illustrates the importance of considering anatomical variations and patient risk factors for visceral arterial occlusions, reducing morbidity and mortality.

Less is more: The use of single biodegradable stenting to treat biliary anastomotic strictures in pediatric liver transplantation

This study reports our experience of using biodegradable biliary stents (BBSs) for anastomotic biliary strictures (ABSs) in pediatric patients undergoing liver transplants. It involves the analysis of a retrospective data collection from January 2014 to January 2023, including all pediatric recipients of liver transplants in our center treated for ABSs with BBSs. In phase 1 (2014-2019), there was an initial percutaneous transhepatic cholangiography with anastomotic dilatation followed 2 weeks after a second percutaneous transhepatic cholangiography with BBS insertion. In phase 2 (2019-2023), the BBS was placed shortly after ABS dilatation, requiring only 1 percutaneous transhepatic cholangiography. All patients were followed up with routine tests and ultrasound. Forty-six ABSs were diagnosed in 43 pediatric recipients of liver transplants with a median of 6.7 months after liver transplantation (0.1-246.8 mo). Eight out of 46 ABSs (17.4%) treated with BBSs relapsed (median recurrence time: 6.5 mo; 1.6-17.0 mo). Four resolved with further BBS placement; only 4 needed surgical revision (8.7%) after a median follow-up time of 43.9 months (0.3-106.3). There were no differences in ABS recurrence rate, time between stent placement and recurrence, or the presence of cholangitis based on whether the BBS was deployed in 1 or 2 steps. Patients with end-to-end anastomosis had a higher ABS recurrence (OR 10.8; 1.4-81.3, p = 0.008) than those with bilioenteric anastomosis. The use of biodegradable stents could be a good option for treating ABSs in pediatric patients undergoing liver transplants, with our series showing a success rate of over 90% and an average follow-up of 43.9 months.

Prediction of Malignancy and Pathological Types of Solid Lung Nodules on CT Scans Using a Volumetric SWIN Transformer

Lung adenocarcinoma and squamous cell carcinoma are the two most common pathological lung cancer subtypes. Accurate diagnosis and pathological subtyping are crucial for lung cancer treatment. Solitary solid lung nodules with lobulation and spiculation signs are often indicative of lung cancer; however, in some cases, postoperative pathology finds benign solid lung nodules. It is critical to accurately identify solid lung nodules with lobulation and spiculation signs before surgery; however, traditional diagnostic imaging is prone to misdiagnosis, and studies on artificial intelligence-assisted diagnosis are few. Therefore, we introduce a volumetric SWIN Transformer-based method. It is a multi-scale, multi-task, and highly interpretable model for distinguishing between benign solid lung nodules with lobulation and spiculation signs, lung adenocarcinomas, and lung squamous cell carcinoma. The technique's effectiveness was improved by using 3-dimensional (3D) computed tomography (CT) images instead of conventional 2-dimensional (2D) images to combine as much information as possible. The model was trained using 352 of the 441 CT image sequences and validated using the rest. The experimental results showed that our model could accurately differentiate between benign lung nodules with lobulation and spiculation signs, lung adenocarcinoma, and squamous cell carcinoma. On the test set, our model achieves an accuracy of 0.9888, precision of 0.9892, recall of 0.9888, and an F1-score of 0.9888, along with a class activation mapping (CAM) visualization of the 3D model. Consequently, our method could be used as a preoperative tool to assist in diagnosing solitary solid lung nodules with lobulation and spiculation signs accurately and provide a theoretical basis for developing appropriate clinical diagnosis and treatment plans for the patients.

Impact of Swallowing Assessment Using the Hyodo-Komagane Score on the Severity of Dysphagia and Medical Staff Workload

BACKGROUND

The goal of dysphagia treatment is to ensure a safe and effective reduction in both dysphagia severity and medical staff workload.

OBJECTIVE

To investigate the correlation of the Hyodo-Komagane score with dysphagia severity and medical staff workload.

METHODS

This retrospective cohort study included 96 patients who were referred from other departments for swallowing evaluation from January to April 2021. The correlation between the Hyodo-Komagane score and dysphagia severity was assessed using the Food Intake LEVEL Scale (FILS) score, and its effect on the reduction in medical staff workload was examined using the feeding assistance level of the referred patients.

RESULTS

This study included 96 hospitalised patients, comprising 15 patients with neuromuscular diseases, eight patients with cardiovascular diseases, 12 patients with head and neck diseases (excluding otolaryngological diseases), 34 patients with internal medicine diseases and 27 patients with cerebrovascular diseases, who underwent swallowing evaluation. The FILS score and feeding assistance level significantly improved at discharge compared with that at referral. A significant correlation was observed between the FILS score and feeding assistance level. The Hyodo-Komagane score was correlated with the feeding assistance level at discharge but not at referral.

CONCLUSION

The Hyodo-Komagane score may optimise rehabilitation and reduce dysphagia severity and medical staff workload, indicating its useful effect on dysphagia severity and medical staff labour.

MRI of early rectal cancer; bisacodyl micro-enema increases submucosal width, reader confidence, and tumor conspicuity

PURPOSE

To investigate the influence of a micro-enema on diagnostic performance, submucosal width, reader confidence, and tumor conspicuity using MRI to stage early rectal cancers (ERC).

METHODS

In this single-center study, we consecutively included 50 participants with assumed ERC who all completed MRI with (MRin) and without (MRex) a micro-enema. The diagnostic performance was recorded for two experienced radiologists using histopathology as the gold standard. In addition, the width of the submucosa in the tumor-bearing wall, reader confidence for T-staging, and tumor conspicuity were assessed. Significance levels were calculated using McNemar's test (diagnostic performance) and Wilcoxon's signed-rank test (reader confidence, submucosal width, and conspicuity). Interreader agreement was assessed using kappa statistics.

RESULTS

Sensitivity/specificity were for Reader1 91%/87% for both MRex and MRin and for Reader2 74%/87% and 89%/87%, both readers p > 0.05. The micro-enema induced a significant widening of the submucosa, p < 0.001, with a mean increase of 2.2/2.8 mm measured by Reader1/Reader2. Reader confidence in T-staging and tumor conspicuity increased for both readers, p < 0.005. The proportion of tumors with both correct staging and high reader confidence increased from 58% (29/50) to 80% (40/50) (p = 0.04) for Reader1 and from 42% (21/50) to 72% (36/50) (p = 0.002) for Reader2. Interreader agreement increased from moderate (kappa 0.58) to good (kappa 0.68).

CONCLUSION

The micro-enema significantly increased the submucosal width in the tumor-bearing wall, reader confidence, and tumor conspicuity and improved interreader agreement from moderate to good. Sensitivity and specificity in T-staging did not improve, but there was a significant increase in the proportion of tumors staged with both high confidence and correct T-stage.

Evaluation of nutrition therapy in critically ill patients with Clostridioides difficile infection

BACKGROUND & AIMS

Nutrition therapy in the intensive care unit (ICU) is a fundamental aspect of care, but there is minimal guidance for patients with Clostridioides difficile infection (CDI) despite the potentially severe consequences of this infection on the gastrointestinal tract. The aim of this study was to assess nutrition therapy in critically ill patients with CDI compared to those without CDI for differences in nutrition delivery, need for nutrition support, and safety of nutrition therapy.

METHODS

This was a single-center, retrospective cohort study of patients admitted to the ICU from January 1, 2013, through December 31, 2022. This study compared nutrition therapy in critically ill patients who had CDI compared to a cohort who had diagnoses of other infections. Outcomes included doses of nutrition prescribed, need for nutrition support, and measures of enteral feeding tolerance.

RESULTS

A total of 66 patients were included in this study, 33 in each group. The CDI group received higher median maximum calories (24.3 kcal/kg/day) compared to the control group (21.7 kcal/kg/day) [MD 3.5, 95 % CI 0.05-7.49, p = 0.04] and higher median maximum protein doses (1.1 g/kg/day) to (0.9 g/kg/day) [MD 0.2, 95 % CI 0.04-0.38, p = 0.02]. In the CDI group, significantly more patients required nutrition support (75.8 % and 48.5 %, respectively) [OR 3.32, 95 % CI 1.16-9.84, p = 0.02], but there was no difference in the number of patients who received parenteral nutrition. Measures of enteral feeding safety and tolerance were similar between both groups.

CONCLUSION

Nutrition therapy for critically ill patients did not appear to be negatively impacted by CDI, and provision of diet or enteral nutrition therapy appeared similarly safe and tolerated compared to those without CDI.

Feeding development in healthy infants: A comparative framework for children with Spinal Muscular Atrophy - The DySMAnorm study

OBJECTIVES

Normative data for swallowing parameters in non-dysphagic, healthy children for instrumental and clinical diagnostics are limited. In children with SMA, where due to the degenerative nature a deterioration in swallowing function in the first months of life is possible despite disease-modifying therapy, regular monitoring is required. The DySMA (Dysphagia in Spinal Muscular Atrophy) is a tool available to assess both physiological feeding development and specific abnormalities in children with SMA. We aimed to generate normative data for the DySMA in a sample of healthy infants to facilitate comparisons with children with SMA.

METHODS

Healthy infants and toddlers aged zero to 24 months were recruited and divided into seven age groups. Two speech-language pathologists assessed the children according to the DySMA study protocol. The data were evaluated descriptively and the inter-rater reliability was calculated.

RESULTS

A total of 92 healthy children were included. The DySMA total score ranged from 21 to 35 and showed excellent inter-rater reliability (ICC = .936; 95 % CI .752 to .984). The maximum score of 35 was first reached from 16 months onwards. Categories representing physiological development showed the most significant age-dependent changes, while no age-related development was observed in categories expressing pathology.

CONCLUSION

The DySMA effectively captures physiological feeding development. A higher total score reflects more comprehensive skills in children, while a lower score indicates a reduced range of abilities. By analyzing the normative sample, this tool makes it possible to represent a deviation from the norm for children with SMA.

Chronic intestinal pseudo-obstruction complicated with sand-like enterolithiasis: case report

Enterolithiasis is typically associated with gastrointestinal tract stasis. Here, we report on a rare case of chronic intestinal pseudo-obstruction with sand-like enterolithiasis in an 18-year-old Japanese female admitted to our hospital with high fever and abdominal pain. Despite initiating antibiotic treatment, the fever persisted. A contrast-enhanced computed tomography revealed colonic enlargement and a large amount of residue with a high-density area in the ascending colon. A colonoscopy revealed sand-like enteroliths in the ascending colon, which were drained using a colonoscope. The patient's symptoms improved significantly after the drainage and antibiotic therapy. The granules were white-brown in color and smaller than 300 μm in size. Infrared spectroscopy indicated similar peaks for crystals and hydroxypropyl cellulose which is an additive used in certain medications. We hypothesized that hydroxypropyl cellulose contributed to the formation of sand-like enteroliths in cases of severe intestinal dysmotility. Intestinal failure may cause enterolithiasis due to an unharmful additive and require careful follow-up.

Intraluminal causes of mechanical small bowel obstruction: CT findings and diagnostic approach

Intraluminal causes of small bowel obstruction (SBO) are less common than mural or extrinsic etiologies. This review categorizes intraluminal causes of SBO into four broad categories to provide a diagnostic framework for radiologic interpretation: 1) ingested contents, 2) bowel stasis, 3) inflammatory causes, and 4) neoplasms. Ingested materials can result in SBO when individual or accumulated contents are too large to pass, such as in the case of foreign bodies or bezoars. Bowel stasis causing SBO can be secondary to abnormal bowel function, such as in cystic fibrosis, reduced transit of contents at sites of narrowing such as surgical anastomoses, or the formation of enteroliths in diverticula which may subsequently dislodge and result in luminal obstruction. Inflammatory causes of SBO include strictures or fistulas that allow foreign bodies (such as gallstones) formed outside the bowel to enter the bowel lumen and cause obstruction. Finally, neoplasms can present as endophytic masses that occlude the bowel lumen through a ball-valve mechanism or serve as a lead point for intussusception. Recognizing the imaging features that are suggestive of intraluminal SBO is critical for accurate diagnosis and timely patient care.

A deep learning-based, real-time image report system for linear EUS

BACKGROUND AND AIMS

The integrity of image acquisition is critical for biliopancreatic EUS reporting, significantly affecting the quality of EUS examinations and disease-related decision-making. However, the quality of EUS reports varies among endoscopists. To address this issue, we developed a deep learning-based EUS automatic image report system (EUS-AIRS), aiming to achieve automatic photodocumentation in real-time during EUS, including capturing standard stations, lesions, and puncture procedures.

METHODS

Eight deep learning models trained and tested using 235,784 images were integrated to construct the EUS-AIRS. The performance of EUS-AIRS was tested through man-machine comparisons at 2 levels: a retrospective test (include internal and external testing) and a prospective test. From May 2023 to October 2023, a total of 114 patients undergoing EUS at Renmin Hospital of Wuhan University were consecutively recruited for prospective testing. The primary outcome was the completeness of the EUS-AIRS for capturing standard stations.

RESULTS

In terms of completeness in capturing biliopancreatic standard stations, EUS-AIRS exceeded the capabilities of endoscopists at all levels of expertise in retrospective internal testing (90.8% [95% confidence interval (CI), 88.7%-92.9%] vs 70.5% [95% CI, 67.2%-73.8%]; P < .001) and external testing (91.4% [95% CI, 88.4%-94.4%] vs 68.2% [95% CI, 63.3%-73.2%]; P < .001). EUS-AIRS exhibited high accuracy and completeness in capturing standard station images. The completeness of the EUS-AIRS significantly outperformed manual endoscopist reports (91.4% [95% CI, 89.4%-93.4%] vs 78.1% [95% CI, 75.1%-81.0%); P < .001).

CONCLUSIONS

EUS-AIRS exhibits exceptional capabilities in real-time, capturing high-quality and high-integrity biliopancreatic EUS images. This showcases the potential of applying an artificial intelligence image report system in the EUS field.

Validation of British Society of Gastroenterology guidelines for acute lower GI bleeding from 8956 cases in Japan

BACKGROUND AND AIMS

We sought to validate the British Society of Gastroenterology (BSG) guidelines for acute lower GI bleeding (ALGIB).

METHODS

We analyzed 8956 patients with ALGIB in the Colonic Diverticular Bleeding Leaders Update Evidence From Multicenter Japanese Study (CODE BLUE-J) study and categorized them into 4 groups based on the BSG guidelines. Outcomes included 30-day rebleeding, 30-day mortality, blood transfusion, therapeutic intervention, and severe bleeding.

RESULTS

The severe bleeding rates significantly decreased from group I to group IV: 92.1%, 70.1%, 58.7%, and 38.4%. The rate of the need for blood transfusion and 30-day mortality also decreased from group I to group IV. Although outpatient follow-up was recommended in group IV, it had high rates of severe bleeding (38%) and 30-day rebleeding (11%). Notably, for colonic diverticular bleeding, the rate of 30-day rebleeding was 25.5%, even with an Oakland score of ≤8. We identified abdominal pain, diarrhea, and a high white blood cell count as independent factors that differentiate between nonsevere and severe bleeding cases in group IV. Using these factors, we found that the 30-day rebleeding rate in the nonsevere group was 3.6%, suggesting the feasibility of outpatient follow-up in this group. Furthermore, a novel group, Group X, which deviated from the existing 4 groups, had a high severe bleeding rate (70.9%) comparable to that of group II.

CONCLUSIONS

The BSG guidelines suggest a management approach that can clearly differentiate severity. However, caution is advised when using the Oakland score to triage patients for outpatient follow-up. Additionally, prompt intervention may be necessary for groups not covered by the guidelines.

Design and Evaluation of an Omnidirectional Wheel-Driven Endoscope-Assisted Robotic System Based on Motion Capture Control

BACKGROUND

In endoscopic surgery, surgeons collaborate with assistants to manipulate the endoscope and instruments, making it impossible to perform the surgery independently.

METHODS

We propose an endoscopic assistive robot based on motion capture control, enabling surgeons to control the endoscope with one hand. The system uses cameras at the master end to capture real-time motion information from the marker accessory, determining the surgeon's intent. It then controls the robot at the slave end to simulate surgical delivery actions, enabling precise endoscopic positioning through master-slave mapping. The omnidirectional wheel design addresses coupling issues of traditional friction wheels, significantly improving control accuracy.

RESULTS

Testing demonstrated a maximum delivery error of 3.99% and 45.77% improvement in rotational precision. The system received positive feedback in both simulated and animal trials.

CONCLUSIONS

The system empowers surgeons to perform endoscopic procedures independently, establishing a foundation for advancing diagnosis and treatment of gastric diseases.

Hemostatic powder TC-325 as first-line treatment option for malignant gastrointestinal bleeding: a cost-utility analysis in the United Kingdom

Randomized controlled trials have shown that hemostatic powder (TC-325) results in greater immediate hemostasis and lower 30-day rebleeding rates than standard endoscopic therapy (SET) for management of malignant upper gastrointestinal bleeding (MUGIB). We explored whether TC-325 would be a cost-effective first-line option for patients with MUGIB compared with SET in the United Kingdom.A decision tree was developed for patients with MUGIB, assessing initial therapy with TC-325 or SET over a 30-day period. Patients with failed initial hemostasis or a rebleed within 30 days underwent further endoscopic treatment, escalation to either transcatheter arterial embolization or surgery, or radiotherapy. Overall 30-day mortality was applied. Costs, in GBP, were based on the United Kingdom National Health Services costs for 2023/2024. Results were reported as incremental differences in cost, quality-adjusted life years (QALY), and net monetary benefit. Deterministic and probabilistic sensitivity analyses and scenario analyses were performed.The cost of treating MUGIB patients with TC-325 was £245.88 lower than treatment with SET, with an incremental increase of 0.001 QALYs. TC-325 remained a cost-saving approach in sensitivity and scenario analyses. Probabilistic sensitivity analysis revealed that TC-325 was more effective and cost saving in 80.1% of simulations (range 67.5%-98.63%).Initial treatment of MUGIB with TC-325 compared with SET was more effective (higher primary hemostasis and lower 30-day rebleeding) and cost saving owing to the requirement for fewer interventions, readmissions, and length of stay. Additional studies are needed to address model uncertainties in the follow-up management of these complex patients.

Dieulafoy Lesion in a Pediatric Patient

OBJECTIVE

Our aim is to describe a rare etiology of an upper gastrointestinal bleeding (UGIB) to help pediatric emergency medicine clinicians improve their understanding of its presentation as well as the standard therapeutic approach to UGIB.

METHODS

This is a retrospective case report of a patient who presented to the Pediatric Emergency Department of Hasbro Children's Hospital and who was found to have a UGIB secondary to a Dieulafoy lesion.

RESULTS

The etiology of UGIBs varies by geography and patient age but includes esophagitis, Mallory-Weiss tears, gastritis, peptic ulcers, and foreign body ingestion. Given the overlapping presenting symptoms, history and physical are critical to identifying likely etiology and guiding treatment. This patient improved after definitive treatment with endoscopy and hemo-clips.

CONCLUSIONS

Children with symptoms of UGIB should receive prompt resuscitation and stabilization, and clinicians should maintain an index of clinical suspicion for less common pediatric pathologies, such as malignancy or arterial bleeding.

Dysphagia Caused by Submucosal Tumor-Like Esophageal Cancer: Two Case Reports

Esophageal squamous cell carcinoma is an aggressive and globally prevalent malignancy that rarely presents as submucosal tumor-like lesions, leading to significant diagnostic challenges. We present two examples of primary esophageal squamous cell carcinoma in which complete intramural invasion mimicked submucosal tumor-like lesions. Initial biopsies suggested benign hyperplasia; however, subsequent endoscopic ultrasound-guided fine needle aspiration confirmed the diagnosis of esophageal squamous cell carcinoma. Both patients received appropriate treatment and showed favorable outcomes. The histopathological feature of intramural esophageal squamous cell carcinoma, characterized by growth confined within the esophageal wall without mucosal epithelial invasion, represents an exceedingly rare and complex pattern. The diagnostic challenges presented by this form of esophageal squamous cell carcinoma highlight the critical role of detailed histopathological examination, with endoscopic ultrasound-guided fine needle aspiration being indispensable for accurate diagnosis and effective management of submucosal tumor-like lesions.

Effect of duodenal papilla morphology on biliary cannulation and complications in patients with common bile duct stones

BACKGROUND

The endoscopic appearance of the major duodenal papilla influences biliary cannulation and complications. This study aimed to investigate the role of major duodenal papillae in the endoscopic treatment of common bile duct (CBD) stones.

METHODS

This retrospective study was conducted at Bishan Hospital of Chongqing Medical University between January 2018 and August 2022. Patients with native papillae who underwent endoscopic treatment for CBD stones were recruited and divided into four groups according to Haraldsson's classification of papillae (types I-IV). Univariate and multivariate logistic regression analyses were used to identify risk factors for difficult cannulation and post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP).

RESULTS

A total of 596 patients with CBD stones were enrolled. The proportion of patients with type I papilla was the highest (n = 231, 38.8%), followed by type III papilla (n = 175, 29.4%), type IV papilla (n = 101, 16.9%) and type II papilla (n = 89, 14.9%). Difficult cannulation occurred in 188 of 596 patients (31.5%), with most cases occurring in those with type III papilla (71/175, 40.6%, P = 0.020). Multivariate logistic analysis revealed that age [odds ratio (OR) = 1.034, 95% confidence interval (CI): 1.021-1.047, P < 0.001], type III papilla (OR = 2.255, 95% CI: 1.439-3.535, P < 0.001), gallbladder in situ (OR = 2.486, 95% CI: 1.346-4.590, P = 0.004), and CBD diameter < 10 mm (OR = 1.600, 95% CI: 1.049-2.441, P = 0.029) were risk factors for difficult cannulation. The total incidence of PEP was 10.9%. Compared with the other types of papillae, the rate of PEP was the highest in those with type I papilla (15.2%, P = 0.030). Multivariate analysis demonstrated that PEP was associated with difficult cannulation (OR = 1.811, 95% CI: 1.044-3.143, P = 0.035) and white blood cells (WBCs) < 10 × 109/L (OR = 2.199, 95% CI: 1.051-4.600, P = 0.036).

CONCLUSIONS

The endoscopic appearance of the major papilla is an important factor that influences both biliary cannulation and outcomes. Type III papilla is more frequently difficult to cannulate in the endoscopic treatment of CBD stones.

Research progress in the treatment of gallstones with laparoscopic and endoscopic surgery: a narrative review

Cholelithiasis, the formation of stones in the gallbladder, is a common surgical condition with an increasing incidence. Laparoscopic cholecystectomy has become the gold standard for the treatment of symptomatic gallstones due to its favorable outcomes. However, with increasing recognition of the gallbladder's importance, this procedure no longer aligns with patients' desire to preserve the organ. Technological advancements and surgical innovations have led to emerging approaches such as natural orifice transluminal endoscopic surgery (NOTES), robot-assisted laparoscopic cholecystectomy, and cholangioscopy. This narrative review examines the current landscape of surgical interventions for gallstones, highlighting both gallbladder-preserving and removal approaches, and aims to provide insight into their respective outcomes and clinical implications.

Wrist-ankle acupuncture alleviates pain in the acute phase of herpes zoster: A randomized controlled trial

Alternative therapeutic strategies for herpes zoster, especially for acute phase pain relief, are still largely unexplored. This study aimed to compare the effects of wrist-ankle acupuncture combined with standard pharmacological treatment versus standard pharmacological treatment alone in relieving pain in the acute phase of herpes zoster. An open-label, randomized, controlled clinical trial was conducted, enrolling patients diagnosed with acute-phase herpes zoster with pain visual analog scale (VAS) scores greater than or equal to 2. The participants were randomly assigned to either the control group receiving standard pharmacological treatment (antiviral therapy combined with pain relievers) alone or the experimental group receiving wrist-ankle acupuncture plus standard pharmacological treatment. VAS pain scores were recorded on days 1-7 and on day 28 after treatment began. Dermatology Life Quality Index scores were assessed both during the pre-treatment phase and at hospital discharge. A total of 106 patients completed the trial protocol and were included in the analysis, with 52 and 54 patients in the control and experimental groups, respectively. The clinical cure rates of pain (the rate of complete absence of pain) in the experimental group was statistically higher than control group on days 7 after treatment began(87.04% vs 65.38%, p < 0.005). The average pain VAS scores of the experimental group were lower than the control group on days 2-6 after treatment began, and they are statistically significant (all p < 0.05). No significant difference was observed between day 7 and day 28 after treatment began (p > 0.05). The Dermatology Life Quality Index scores significantly differed at hospital discharge (p < 0.05). Side effects did not significantly differ between the two groups (all p > 0.05). Wrist-ankle acupuncture combined with standard pharmacological treatment may potentially improve the pain cure rate at 7 days post-treatment. This suggests a potential new strategy for alleviating pain in patients in the acute phase of herpes zoster. Trial registration: ChiCTR2300071795.