Sustainability in gastroenterology and digestive endoscopy: Position Paper from the Italian Association of Hospital Gastroenterologists and Digestive Endoscopists (AIGO)

Climate crisis is dramatically changing life on earth. Environmental sustainability and waste management are rapidly gaining centrality in quality improvement strategies of healthcare, especially in procedure-dominant fields such as gastroenterology and digestive endoscopy. Therefore, healthcare interventions and endoscopic procedures must be evaluated through the 'triple bottom line' of financial, social, and environmental impact. The purpose of the paper is to provide information on the carbon footprint of gastroenterology and digestive endoscopy and outline a set of measures that the sector can take to reduce the emission of greenhouse gases while improving patient outcomes. Scientific societies, hospital executives, single endoscopic units can structure health policies and investment to build a "green endoscopy". The AIGO study group reinforces the role of gastrointestinal endoscopy professionals as advocates of sustainability in digestive endoscopy. The "green endoscopy" can shape a more sustainable health service and lead to an equitable, climate-smart, and healthier future.

Correct use of telemedicine in gastroenterology, hepatology, and endoscopy during and after the COVID-19 pandemic: Recommendations from the Italian association of hospital gastroenterologists and endoscopists (AIGO)

The purpose of the present document is to provide detailed information on the correct and optimal use of digital media to ensure continuity of care for gastroenterological patients in everyday clinical practice, in health emergencies and/or when the patient cannot reach the hospital for other reasons. During the recent COVID-19 pandemic, telemedicine has allowed many patients with chronic diseases to access remote care worldwide, proving to be the ideal solution to overcome restrictions and carry out non-urgent routine follow-ups on chronic patients. The COVID-19 pandemic has therefore made organizational and cultural renewal essential for the reorganization of healthcare in order to ensure greater continuity of care with a minimum risk of spreading the virus to users, practitioners and their families. These AIGO recommendations are intended to provide Italian gastroenterologists with a tool to use this method appropriately, in compliance with current legislation, in particular the proper approach and procedures for conducting a remote examination using a video conferencing tool, the so-called televisit. In the near future, telemedicine may contribute to a possible reorganization of healthcare systems, through innovative care models focusing on the citizen and facilitating access to services throughout the entire Country.

Could JC virus be linked to chronic idiopathic intestinal pseudo-obstruction?

JC virus is a member of the Polyomavirus family, infects humans worldwide, and 90% of the population carry antibodies to the virus by adult life. The initial infection is asymptomatic, but it may become persistent. JC virus DNA is frequently present in the upper and lower gastrointestinal tracts of healthy adults. Chronic idiopathic intestinal pseudo-obstruction, one of the most severe gastrointestinal motility disorders, is a condition characterized by a clinical picture mimicking small bowel occlusion with related symptoms and signs in the absence of demonstrable mechanical obstruction. Because of the known neuropathic capability of this virus, and its frequent presence in the gut, it has been proposed that JCV might be detectable in tissues of patients with chronic idiopathic intestinal pseudo-obstruction, and possibly be involved in the pathogenesis of this disease, because the virus may actively infect the enteroglial cells of the myenteric plexuses of the patients with chronic idiopathic intestinal pseudo-obstruction. We report two cases of upper idiopathic intestinal pseudo-obstruction associated with JCV infection.

A difficult diagnosis of coeliac disease: Repeat duodenal histology increases diagnostic yield in patients with concomitant causes of villous atrophy

Villous atrophy in absence of coeliac disease (CD)-specific antibodies represents a diagnostic dilemma. We report a case of a woman with anaemia, weight loss and diarrhoea with an initial diagnosis of seronegative CD and a histological documented villous atrophy who did not improve on gluten-free diet due to the concomitant presence of common variable immunodeficiency (CVID) and Giardia lamblia infection. This case report confirms that CD diagnosis in CVID patients is difficult; the combination of anti-endomysial antibodies (EmA-IgA), anti-tissue transglutaminase antibodies (tTG-IgAb) antibodies and total IgA is obligatory in basic diagnostic of CD but in CVID are negative. Furthermore, the typical histological aspects of the intestinal mucosa in CVID (absence of plasma cells and switch to the IgD immunoglobulins), cannot rule out a concomitant CD diagnosis. HLA typing in this setting has a low positive predictive value but should be considered. Histological response to a gluten-free diet on repeat biopsy and the concomitant treatment of other causes of villous atrophy leads to a definite diagnosis of CD.

Is Epstein-Barr virus infection associated with the pathogenesis of microscopic colitis?

BACKGROUND

Epstein-Barr virus (EBV) has been associated with inflammation in the colon, particularly in patients with inflammatory bowel disease (IBD). Even if a relevant plasmocytosis, similar to IBD, is present in microscopic colitis (MC), the frequency of EBV infection in this setting is unknown.

OBJECTIVES

We aimed to compare the frequency of colonic EBV infection in patients with MC, ulcerative colitis (UC), and irritable bowel syndrome (IBS).

STUDY DESIGN

The frequency of colonic EBV infection in biopsies of 30 patients with MC, 30 patients with UC, and 30 controls with IBS was retrospectively assessed. PCR was performed to detect viral EBV DNA in colonic biopsies. In situ hybridization was also performed to identify and localize EBV-encoded small RNA1 and 2 (EBERs) within cells.

RESULTS

The presence of EBV DNA was detected in 27 out of 30 MC patients, in 20 out of 30 UC cases, and in none of IBS group. The frequency of EBV DNA in MC was significantly higher compared with that reported in UC (90.0% vs. 66.7%, p=0.03). EBERs+ cells were observed in 18 out of 30 MC patients, in only 3 out of 30 UC patients (60.0% vs. 10.0%, p<0.001), and in none of IBS group.

CONCLUSIONS

EBV infection is almost always detectable in the colonic mucosa of patients with MC. Further studies are necessary to confirm this association and to clarify the role of EBV in MC and, more generally, in colonic inflammation.

Self-expandable metal stents for malignant colonic obstruction: data from a retrospective regional SIED-AIGO study

BACKGROUND

Self-expandable metal stents are a non-surgical option for the treatment of symptomatic malignant colorectal obstruction as palliative treatment or as a bridge to surgery.

AIMS

To report data from a regional study on self-expandable metal stent (SEMS) placement for malignant colorectal obstruction.

METHODS

Two hundred and four patients (male 54.9%, mean age of 69.5 ± 14.2) were retrospectively evaluated and data on technical and clinical success, and complications, were analyzed.

RESULTS

Technical and clinical success rates were 99% and 94.6% respectively, with 36.7% treated on an emergency basis and 63.3% electively. Palliative treatment was administered to 70.1%, and as a bridge to surgery for 29.9%. Complications were 17 neoplastic ingrowths, 10 stent migrations, and 4 perforations. Palliative treatment was associated with a higher risk of stent ingrowth (p=0.003), and chemotherapy with a lower risk of stent ingrowth (p=0.009).

CONCLUSION

This regional study, although it has certain limitations, confirms the positive role of self-expandable metal stents in the treatment of symptomatic malignant colorectal obstruction, and that chemotherapy decreases the risk of ingrowth.

Delayed-onset superior mesenteric artery syndrome presenting as oesophageal peptic stricture

Superior mesenteric artery (SMA) syndrome is an infrequent cause of vomiting and weight loss due to compression of the third part of the duodenum by the SMA. We describe the case of a 17-year-old woman, admitted to our department for progressive dysphagia and severe weight loss due to an oesophageal peptic stricture, caused by chronic acid reflux secondary to duodenal compression by the SMA. Symptoms improved after (par)enteral nutrition and repeated oesophageal dilatation, thus supporting the role of intensive medical and endoscopic intervention as an alternative to surgery, at least in some cases.

Efficacy and safety of endoscopic balloon dilation of symptomatic intestinal Crohn's disease strictures

AIM

To evaluate prospectively the clinical efficacy and safety of endoscopic hydrostatic balloon dilation in a consecutive cohort of symptomatic intestinal Crohn's disease strictures.

METHODS

Between September 2003 and December 2008 we performed endoscopic balloon dilations in 37 Crohn's disease patients with 39 intestinal symptomatic strictures (4 naïve and 35 postoperative). Dilations were performed using a Rigiflex through-the-scope balloon. Clinical success rate was claimed if a patient remained asymptomatic and did not require surgery or further endoscopic dilation, following technical success. Actuarial curves of clinical, endoscopic (redilation) and surgical recurrence were obtained by Kaplan-Meier method. Demographic and disease variables were related to the main outcomes.

RESULTS

After a mean follow-up of 26.3 months (range, 2-61 months), the long-term global benefit rate was 89% (33/37). The 1-2-3 years cumulative symptom-free rates were respectively: 76%, 55% and 46%. Four patients were operated upon. Technical success predicts a lower rate of surgery. There were no complications related to the endoscopic procedures.

CONCLUSIONS

Endoscopic balloon dilation of symptomatic Crohn's disease strictures may achieve clinical benefit in many patients and is a valid alternative to surgery in the management of the disease. Dilation may be repeated in recurrent intestinal obstructions and appears safe without morbidity.

Music for colonoscopy: A single-blind randomized controlled trial

BACKGROUND

Several methods have been reported to minimize patient discomfort during colonoscopy, none are currently recommended by clinical practice guidelines. We performed a single-blind randomized controlled trial to assess the efficacy of music for colonoscopy.

METHODS

109 patients were randomized to music-delivering or mute headphones before and during colonoscopy. Physicians were blinded to the trial. Sedation was given on demand. Primary outcome was pain measured on linear analogue scale from 0 to 10. Secondary endpoints were the difficulty of the procedure, need of sedation, overall patient satisfaction and willingness to repeat the procedure.

RESULTS

Mean pain score was 5.9±2.2 in the control group vs. 3.8±1.9 in the music group (p<0.00001); correspondingly overall satisfaction and willingness to repeat the procedure were significantly improved by music and the difficulty perceived by physicians was significantly reduced. Total administered midazolam was 36mg in the control group vs. 13 in the music group (p<0.007), pethidine was 860mg vs. 465mg (p=0.07) and patients requiring sedation were 22 vs. 9, respectively (p=0.003). A multivariable analysis to adjust treatment effect for potential confounding factors confirmed the significant beneficial effect of music.

CONCLUSIONS

Music significantly reduces discomfort and should be routinely offered to patients undergoing colonoscopy.