Endoscopic Abnormalities Research Articles

Esophagitis, treatment outcomes, and long-term follow-up in children with esophageal atresia.

Survival rates in children born with esophageal atresia (EA) with or without tracheoesophageal fistula (TEF) have improved; however, morbidity associated with the disease remains high. This study aimed to assess the prevalence of gastroesophageal reflux disease (GERD), eosinophilic esophagitis (EoE), fungal esophagitis, esophageal strictures, and long-term outcomes in children with EA/TEF. We conducted a retrospective chart review on patients with EA/TEF who were seen at Children's Wisconsin from January 2003 to January 2023. Patients born with EA/TEF were included if they underwent at least one endoscopy after 1 year of age. GERD was diagnosed based on abnormal findings on endoscopy, pH-metry, and/or history of fundoplication. EoE and fungal esophagitis were diagnosed based on abnormal endoscopy. Esophageal stricture diagnosis was based on findings on endoscopy and/or esophagram, and clinical symptoms necessitating esophageal dilation. Eighty-five patients (64.7% males, mean age 7.5 years) were included, the majority had type C EA/TEF (90.6%). GERD was diagnosed in 61.1% (n = 52), 49.4% (n = 42) by macro and/or microscopic endoscopic findings, 22.3% (n = 19) by abnormal pH-metry, and 21.1% (n = 18) by the need for fundoplication for refractory reflux and/or esophageal stricture. Risk of GERD increased with lower gestational age (p = 0.0030), lower birth weight (p = 0.023), and long-gap EA (p = 0.034). In children diagnosed with GERD, only 13.4% of patients (n = 7/52) were able to be weaned off proton pump inhibitor (PPI) without disease recurrence. However, overall, at the completion of the study, 44.7% (n = 38) of patients were successfully weaned off PPI without evidence of GERD. EoE was diagnosed in 20% of the patients (n = 17). All patients diagnosed with EoE required escalation of therapy from PPI alone to swallowed corticosteroids in 52.9% (n = 9), dupilumab in 23.5% (n = 4), elemental formula in 17.6% (n = 3), and elemental formula and swallowed steroids in 5.8% (n = 1). Fungal esophagitis was diagnosed in 15.3% of patients (n = 13). An esophageal stricture requiring dilation was diagnosed in 77.6% (n = 66) of patients at a mean age of 28.5 months, with over 60% diagnosed by 24 months of age. Children born with EA/TEF continue to be at high risk of developing GERD, EoE, fungal esophagitis, and esophageal stenosis. Diagnostic and therapeutic endoscopy remains a high-yield test to identify and treat these comorbidities.

Association of endoscopic findings and histological alterations in pediatric Crohn's disease.

Crohn's disease (CD) is a type of inflammatory bowel disease (IBD) characterized by chronic, transmural, and relapsing inflammation that can affect any segment of the gastrointestinal tract, from the oral cavity to the anus (1). The clinicopathological association of various endoscopic abnormalities in CD is under study. An analytical study was conducted on patients under the age of 15 who underwent esophagoscopy and/or colonoscopy for suspected IBD at a pediatric hospital between 2015 and 2022 (Reg. No. 3318-0000206). Subjects with normal histopathological findings and those with a histological diagnosis of CD were included. The prevalence of different endoscopic alterations and their association with histopathological abnormalities were compared between patients with Crohn's disease (CD) and those with normal histology (NCD). Of the 502 endoscopies performed during this period, 22 subjects with CD and 14 children with NCD were included. Endoscopic normality, defined as the absence of mucosal abnormalities, was higher among NCD patients (43%), while the most prevalent macroscopic abnormality in CD patients was the presence of ulcers.

Clinical-pathological correlation of endoscopic findings in eosinophilic esophagitis in the pediatric population.

Eosinophilic esophagitis (EoE) is an immunologic disorder of the esophagus with an increasing incidence in our region of 8.1 cases per 100,000 inhabitants per year. It is characterized by dysphagia, and its diagnosis requires esophagoscopy with biopsies for histopathological analysis, which macroscopically reveals certain characteristic endoscopic findings, though their diagnostic utility remains uncertain. The correlation between these endoscopic findings and the histopathological diagnosis of EoE continues to be a subject of controversy in the pediatric population. This study evaluates the clinical-pathological association of different endoscopic abnormalities in EoE. We conducted an analytical study of patients under 15 years old who underwent esophagoscopy due to highly suspicious symptoms of EoE at a pediatric hospital between 2015 and 2022.

Correlation of endoscopic findings with histological alterations in pediatric ulcerative colitis.

Ulcerative colitis (UC) is a chronic and relapsing inflammatory bowel disease (IBD) characterized by abdominal pain and bloody diarrhea. Its diagnosis requires endoscopy and biopsies for histopathological analysis, revealing characteristic endoscopic findings. Currently, the correlation between these endoscopic abnormalities and the histopathological diagnosis of UC remains a controversial topic in pediatrics. This study evaluates the clinicopathological association of various endoscopic alterations in UC. We conducted an analytical study of patients under 15 years old who underwent upper and lower gastrointestinal endoscopy for suspected IBD at a pediatric hospital between 2015 and 2022.

Differential changes in mast cells with food reintroduction in children with Eosinophilic Esophagitis.

Intraepithelial mast cells (MC) are increased in Eosinophilic Esophagitis (EoE) and reduced with elimination of dietary antigens. Single food reintroduction can identify triggers of eosinophilia however it remains unknown the extent to which specific foods trigger intraepithelial mastocytosis. We hypothesized that specific foods drive different degrees of MC inflammation. We previously reported a prospective pediatric EoE cohort treated with a 4-food elimination diet (4FED) with removal of soy, egg, wheat, milk. We retrieved unstained slides in which baseline, 4FED, and post-4FED diet reintroduction time points were available. Slides were stained with tryptase, and intraepithelial MCs were counted. Comparisons were made by stratifying patients by eosinophilia, basal cell hyperplasia (BCH), endoscopic abnormalities, and symptoms. Pearson correlation was assessed for MCs with eosinophilic, endoscopic and BCH severity, symptoms, and a novel mucosal activity score (MAS) combining endoscopic and histologic structural severity. Slides were available from 37 patients with at least 1 food reintroduced. MCs were significantly reduced with 4FED. Wheat led to increased intraepithelial MCs in the upper esophagus and with food-induced eosinophilia, while milk led to significantly increased MCs in the upper and lower esophagus and was significantly associated with patients with food-triggered eosinophilia, endoscopic abnormalities, BCH, and symptoms. MCs best correlated with the MAS during milk reintroduction. In children with EoE, MCs are reduced with 4FED. During milk reintroduction, significant increases in MCs were observed with all metrics of inflammation along with moderate correlation with structural mucosal activity that was not seen with other foods. This suggests milk exerts unique effects either directly or indirectly on MCs in the esophagus in EoE patients.

Eosinophil Depletion with Benralizumab for Eosinophilic Esophagitis

BackgroundBenralizumab is an eosinophil-depleting anti–interleukin-5 receptor α monoclonal antibody. The efficacy and safety of benralizumab in patients with eosinophilic esophagitis are unclear.MethodsIn a phase 3, multicenter, double-blind, randomized, placebo-controlled trial, we assigned patients 12 to 65 years of age with symptomatic and histologically active eosinophilic esophagitis in a 1:1 ratio to receive subcutaneous benralizumab (30 mg) or placebo every 4 weeks. The two primary efficacy end points were histologic response (≤6 eosinophils per high-power field) and the change from baseline in the score on the Dysphagia Symptom Questionnaire (DSQ; range, 0 to 84, with higher scores indicating more frequent or severe dysphagia) at week 24.ResultsA total of 211 patients underwent randomization: 104 were assigned to receive benralizumab, and 107 were assigned to receive placebo. At week 24, more patients had a histologic response with benralizumab than with placebo (87.4% vs. 6.5%; difference, 80.8 percentage points; 95% confidence interval [CI], 72.9 to 88.8; P<0.001). However, the change from baseline in the DSQ score did not differ significantly between the two groups (difference in least-squares means, 3.0 points; 95% CI, –1.4 to 7.4; P=0.18). There was no substantial between-group difference in the change from baseline in the Eosinophilic Esophagitis Endoscopic Reference Score, which reflects endoscopic abnormalities. Adverse events were reported in 64.1% of the patients in the benralizumab group and in 61.7% of those in the placebo group. No patients discontinued the trial because of adverse events.ConclusionsIn this trial involving patients 12 to 65 years of age with eosinophilic esophagitis, a histologic response (≤6 eosinophils per high-power field) occurred in significantly more patients in the benralizumab group than in the placebo group. However, treatment with benralizumab did not result in fewer or less severe dysphagia symptoms than placebo. (Funded by AstraZeneca; MESSINA ClinicalTrials.gov number, NCT04543409.)

A160 A CASE OF BREAST CANCER METASTASIS MASQUERADING AS SIGNET RING CELL ADENOCARCINOMA OF THE STOMACH

Abstract Background Gastric cancer has a poor prognosis, particularly at advanced stages. Endoscopic submucosal dissection (ESD) can be used to treat selected early-stage gastric cancers. This case study explores the challenge of diagnosing and managing patients when metastatic lesions mimic primary gastric cancer, as seen in this case of breast cancer metastasis resembling signet ring cell adenocarcinoma of the stomach. Aims The aim of this case report is to describe an unusual case of breast cancer metastasis to the stomach identified unexpectedly on random gastric biopsies, initially diagnosed as a primary gastric signet ring cell adenocarcinoma. Methods Clinical and pathological records of the described patient were reviewed retrospectively. Furthermore, a review of the relevant literature was also performed. Results A 68 year-old-woman underwent gastroscopy for nausea and vomiting. Her past medical history was remarkable for bilateral mastectomies ten years ago for invasive lobular carcinoma, with metastatic bone disease diagnosed by imaging five years prior. She had been well controlled on letrozole taken intermittently due to side effects. At endoscopy, while the stomach appeared grossly normal, random biopsies done for Helicobacter pylori identified a single focus of signet ring cell adenocarcinoma. Subsequent chromoendoscopy identified an area of subtle mucosal abnormality for which the patient declined surgery and was instead managed by ESD which surprisingly yielded no dysplasia. A follow up gastroscopy with random biopsies also failed to identify any areas of dysplasia, but random biopsies on a subsequent gastroscopy again identified a minute focus of adenocarcinoma with signet ring cell morphology. Given the unusual presentation of apparent signet ring cell adenocarcinoma in two distinct areas in the stomach without any visible endoscopic abnormality an in-depth pathological analysis was conducted. By immunohistochemistry the tumor cells stained positive for Estrogen Receptor, GATA3, and CK7 and negative for antibodies targeting CK20 and CDX2, which supported an interpretation of minute multifocal breast cancer metastases to the stomach from hematogenous spread. Conclusions In this case, repeated endoscopic investigations and immunohistochemical staining revealed minute multifocal breast cancer metastases to the stomach. Conventional tumor staging methods often cannot identify microscopic metastases, potentially impacting disease progression and patient care. A high level of suspicion for metastatic breast cancer and a detailed pathological analysis allowed for the correct diagnosis in this patient. Funding Agencies None

Marginal Ulcer Incidence and the Population of Gastrin Producing G cells Retained in the Gastric Pouch after Roux-en-Y Gastric Bypass: Is There a Relationship?

Marginal ulcers are the most prevalent endoscopic abnormality after RYGB. The etiology is still poorly understood; however, an increase in acid secretion has been strongly implicated as a causal agent. Although gastrin is the greatest stimulant of acid secretion, to date, the presence of gastrin producing G cells retained in the gastric pouch, related to the occurrence of marginal ulcers, has not been evaluated. Evaluate the density of G cells and parietal cells in the gastric pouch of RYGB patients with a diagnosis of marginal ulcer on the post-op EGD. We retrospectively evaluated 1104 gastric bypasses performed between 2010 and 2020. Patients with marginal ulcer who met the inclusion criteria and controls were selected from this same population. Endoscopic gastric pouch biopsies were evaluated using immunohistochemical study and HE staining to assess G cell and parietal cell density. In total, 572 (51.8%) of the patients performed endoscopic follow-up after RYGB. The incidence of marginal ulcer was 23/572 (4%), and 3 patients required revision surgery due to a recalcitrant ulcer. The mean time for ulcer identification was 24.3months (2-62). G cell count per high-power field (× 400) was statistically higher in the ulcer group (p < 0.05). There was no statistical difference in parietal cell density between groups (p 0.251). Patients with a marginal ulcer after gastric bypass present a higher density of gastrin-producing G cells retained in the gastric pouch.

The post-COVID-19 intestinal damages: clinical, endoscopic and morphological features. The results of a single-center prospective observational cohort study

Background: Clinical signs of gastrointestinal disorders can manifest both from the first days of COVID-19 and after recovery, and may last up to 6 months or more. Most studies examined the gastrointestinal changes in acute coronavirus infection, whereas intestinal abnormalities in the early and late post-COVID period and their causes have not been sufficiently studied.&#x0D; Aim: To determine the frequency and types of clinical, endoscopic and morphological abnormalities in patients with post-COVID-19 intestinal lesions.&#x0D; Materials and methods: This was a prospective, observational, open-label, cohort, non-controlled study in 72 patients with intestinal symptoms after the coronavirus infection (female 48, mean age 54.6 (95% confidence interval 51.08–58.12) years), who were admitted to the Department of Gastroenterology of general hospital during the first and second waves of COVID-19 from June 2020 to September 2021. The assessment included routine anamnestic, clinical, laboratory, endoscopic, and morphological methods. When indicated, visualization methods (ultrasound, computed tomography, magnetic resonance imaging) were performed. The treatment was symptom-oriented and aimed at inflammation, anemia and protein and electrolyte abnormalities. Outcomes were assessed by the time of discharge from the hospital and thereafter by telephone interviewing of the patients for 8 weeks.&#x0D; Results: In all patients, the main symptom was diarrhea, which started right just after SARS-CoV-2 infection with negative PCR test or 2–4 weeks later. The average stool frequency was 6.8 (5.61–7.99) times daily. In 19/72 patients (26.4%), there were blood and mucus in stools. 2.8% of the patients developed massive intestinal bleeding. Fever was present in 40.3% of the patients, decreased hemoglobin levels in 44.4%, and hypoalbuminemia in 16.7%. Signs of systemic inflammation (increased erythrocyte sedimentation rate, C-reactive protein, fibrinogen, thrombocytosis, leukocytosis) were found with various frequencies in a half of the patients. Clostridioides difficile A and B toxins were identified in 38.9% of the cases and increased fecal calprotectin in 22.2%.&#x0D; Ileocolonoscopy was performed in 67 patients. The colonic mucosa in 21 (31.3%) patients either was not different from the normal, or showed minimal inflammatory changes such as absence of vascular pattern, hyperemia, mild friability even in patients with severe diarrhea, fever and laboratory abnormalities. Pseudomembranous colitis was diagnosed in 12 (17.9%) patients, and focal hemorrhagic colitis in 11 (16.4%) patients. In 2 (3%) cases, moderate to severe ulcerative colitis was newly diagnosed after the SARS-CoV-2 infection. Single or multiple erosions and ulcers of various sizes against the unchanged surrounding mucosa were found in 19 (28.4%) patients. In 2 (3%) cases with profuse intestinal bleeding, the endoscopy showed diffuse spontaneous bleedings from colonic mucosa, with no local source of bleeding found.&#x0D; Biopsy samples from colonic mucosa were taken from 47 patients. Morphological abnormalities of only moderate or dense lymphoplasmocytic infiltration were detected in 29 (67.7%) patients, erosions in 8 (17%). In 2 (4.3%) cases, highly dense lymphoid infiltration with neutrophils, eosinophils and crypt abscesses was found, as typical for ulcerative colitis. In 2 (4.3%) patients, the lymphoid infiltration was associated with small venular and arteriolar clots, and in 5 (10.6%) patients there were no significant morphological abnormalities, except mild lymphoid infiltration.&#x0D; During the hospitalization period, 56.9% of the patients showed a decrease in stool frequency, improvement of clinical and laboratory signs of systemic inflammation and metabolic abnormalities, and partial restoration of their body weight. One patient with ulcerative colitis received adalimumab and achieved stable clinical and endoscopic remission. Complete recovery was noted in 27.8% of the cases within 4–8 weeks, among them in 1 patient who had had profuse intestinal bleedings. In 3 cases (4.2%), an emergency colectomy was performed due to severe pseudomembranous colitis. Two (2.8%) deaths were registered: one patient with newly diagnosed post-COVID severe ulcerative colitis died of pneumonia, and another patient died of severe multiorgan failure. In 6 (8.3%) cases, a moderate long-term (above 8 weeks) diarrhea with metabolic disorders, weight loss, but without systemic inflammation was noted.&#x0D; Conclusion: In patients with post-COVID intestinal lesions, the clinical symptoms are almost the identical and manifest with diarrhea of varying severity, systemic inflammation and metabolic disorders, whereas the endoscopic and morphological lesions are quite diverse. The severity of clinical symptoms often does not correspond to poorly expressed endoscopic and morphological signs. The variability and inconsistency of the clinical, endoscopic and morphological changes have not yet been systematized and do not allow for a clearly formulated diagnosis (except cases of pseudomembranous and ulcerative colitis). This makes it impossible to provide pathophysiologically-based treatments.

Helicobacter pylori infection is associated with decreased odds for eosinophilic esophagitis in Mexican patients

BackgroundThe incidence of eosinophilic esophagitis (EoE) is increasing in some regions of the world. Retrospective studies have found an inverse association with Helicobacter pylori infection (H. pylori). A recent prospective study has questioned this relationship. We aimed to evaluate this relationship in Mexican patients. Patients and methodsWe evaluated adult patients without prior eradication of H. pylori. Cases were defined by the presence of esophageal symptoms and >15 eosinophils/high power field (HPF) in the esophageal biopsy. Controls were defined by the presence of <15 eosinophils/HPF in esophageal biopsy. H. pylori infection was defined by histology. Patients were matched by age and gender assigning four controls per case. ResultsWe included 190 patients: 38 cases and 152 controls. Cases had higher frequency of atopy, dysphagia, food impaction, peripheral eosinophilia, and endoscopic EoE abnormalities. The overall prevalence of H. pylori was 63.6%. Cases had significantly lower prevalence of H. pylori than controls (36.8% vs. 70.4%, OR 0.21 95% CI 0.08–0.69, p = 0.001). Atopic patients had lower prevalence of H. pylori than non-atopic: 13.1% vs. 50.5% (OR 0.20, 95% CI 0.06–0.69, p < 0.001), particularly allergic rhinitis and food allergy. ConclusionsWe observed an inverse relationship between H. pylori and EoE as well as atopy. Studies in experimental models of EoE that clarify the role of H. pylori in this interaction are required, as well as robust studies that include other factors (socioeconomic, cultural, microbiota, etc.) in order to clarify this relationship.

MUCIN MRNA ISOFORM SIGNATURES AS POTENTIAL NOVEL BIOMARKERS TO EVALUATE DISEASE STATUS IN PATIENTS WITH INFLAMMATORY BOWEL DISEASES

Abstract Mucosal barrier dysfunction and aberrant mucin expression are major hallmarks in the pathophysiology of IBD. Mucins are highly polymorphic, and the presence of genetic differences can alter gene expression, resulting in several mRNA isoforms via alternative splicing. While most isoforms encode similar biological functions, others alter protein function, potentially resulting in progression towards disease. Currently, little attention has been given to the importance of mucin mRNA isoforms in IBD. The aim of our study is to investigate the potential of mucin mRNA isoforms as novel biomarkers for the evaluation of IBD activity and subtypes. To obtain this goal, RNA was extracted from colonic and terminal ileal biopsies of IBD patients that underwent an endoscopy at the Antwerp University Hospital (UZA). Additionally, patients without a history of IBD undergoing an endoscopy due to a positive iFOBT which show no endoscopic abnormalities, were included as controls. Library preparation was performed with the PacBio Iso-Seq multiplex protocol adapted for targeted transcriptome sequencing. Targeted capture was accomplished by using a custom-designed pool of probes, developed for the capture of all mucin gene transcripts. Samples were sequenced on the PacBio Sequel platform at the University of Antwerp. The data was analyzed by using the isoseq3-pipeline and additional filtering with SQANTI3 was performed. In total 106 biopsies were sequenced on the PacBio platform. The resulting intestinal mucin transcriptome was merged with the human reference transcriptome. On this combined mucin transcriptome Illumina bulk RNA sequencing data from over 2000 intestinal biopsies (GEO dataset GSE193677) were mapped to determine mucin isoform expression. An external dataset (GEO dataset GSE165512) was used for additional validation. A classification random forest was trained on this data to distinguish inflamed IBD from non-inflamed control patients based on the mucin isoform expression alone. The model performed well on train and test datasets but decreased in the external validation (Table 1). Dividing the samples based on disease phenotype greatly increases performance on the external validation dataset (Table 1). When only training on ileal biopsies, the model proved to be excellent in distinguishing Crohn’s disease patients from controls (Table 1). Classification of inflamed ulcerative colitis from control patients based on only the biopsies from the distal colon was similar to the latter (Table 1). Our machine learning model was able to distinguish Crohn’s disease from control patients and ulcerative colitis from control patients based on mucin mRNA isoform expression. In addition, our data suggests that the mucin isoform expression may vary between different regions within the colon. Table 1 Area under the receiver operator curve (AUCROC) from a random forest classifier trained on mucin isoform expression of inflamed biopsies of IBD and non-inflamed control patients.

P983 Treatment of patients with moderate-to-severe Crohn’s disease with subcutaneous infliximab leads to an endoscopic response across all segments of the colon and terminal ileum: A post hoc analysis of the LIBERTY-CD study

Abstract Background Mucosal healing (MH) has been associated with positive long-term clinical and surgical outcomes in patients (pts) with Crohn’s disease (CD).1 Patterns of MH vary by therapeutic agent, with limited efficacy in the terminal ileum.2–4 This post hoc analysis aimed to investigate the pattern of endoscopic MH across intestinal segments in pts who received subcutaneous (SC) infliximab (IFX) maintenance treatment in the Phase 3 LIBERTY-CD study. Methods LIBERTY-CD demonstrated superior efficacy of SC CT-P13 120 mg every 2 weeks (Q2W) vs placebo (PBO) after IV IFX induction for clinical remission and endoscopic response at Week (W) 54.5 This post hoc analysis evaluated centrally read and batch analysed Simple Endoscopic Score for Crohn's Disease (SES-CD) values obtained at screening, W22 and W54 for 5 ileocolonic segments (rectum; left, transverse and right colon; and terminal ileum). Pts with missing data or who underwent dose escalation to SC IFX 240 mg Q2W upon loss of response from W22 were imputed as non-responders. Endoscopic complete MH (CMH; defined as SES-CD=0) or partial MH (PMH; defined as ≥50% decrease in the SES-CD from screening) were evaluated for segments that had endoscopic abnormalities at screening (segmental SES-CD ≥1 at screening). Results were analysed descriptively. Results Among all randomised pts (N=343; SC CT-P13: n=231, PBO: n=112), the most frequently affected segment at screening was the left colon (187/343; 54.5%), followed by the right colon (185/343; 53.9%), rectum (163/343; 47.5%), terminal ileum (156/343; 45.5%) and transverse colon (134/343; 39.1%). In an analysis of all affected segments, endoscopic CMH rates were higher with SC CT-P13 vs PBO (Figure 1A). Endoscopic CMH rates in the terminal ileum at W54 were 46.7% and 19.6% in the SC CT-P13 and PBO arm, respectively (p=0.0014). PMH rates were also significantly higher in the SC CT-P13 arm across all segments at W22 and W54 (Figure 1B), with rates in the terminal ileum of 64.8% and 33.3% in the SC CT-P13 and PBO arm, respectively (p=0.0003). Conclusion SC IFX 120 mg Q2W led to high and consistent endoscopic MH rates across all segments, including the terminal ileum. Early observation of endoscopic MH (at W22) underscores the potency of SC IFX treatment. Further studies are warranted to investigate the association between segmental MH and long-term outcomes. 1Otte ML et al. World J Gastroenterol 2023;29:1157–72. 2Danese S et al. Gastroenterology 2019;157:1007–18. 3Reinisch W et al. J Crohns Colitis 2017;11:425–34. 4Wu Y et al. Therap Adv Gastroenterol 2020;13:1756284820976923. 5Hanauer SB et al. Gastroenterology 2023;164(S6):S220–1.

P432 Real-time automated assessment of histological disease activity in patients with ulcerative colitis using single wavelength endoscopy technology

Abstract Background Assessment of mucosal healing as a key denominator in the treat-to-target strategy for managing ulcerative colitis remains challenging. To address this, objective evaluation of histological disease activity holds promise. Recent offline research shows encouraging results using a new deep-learning convolutional neural network based on single wavelength endoscopy technology (SWE-CAD) (Fujifilm Co, Japan). We aimed to validate the real-time performance of a new bedside prototype SWE-CAD model during standard colonoscopy. Methods A bedside module for real-time use was integrated in the endoscopy room to evaluate histological disease activity in patients with ulcerative colitis with Mayo Endoscopic Scoring (MES) ranging between 0 and 3. Imaging was performed in rectum and sigmoid following a standardized protocol based on white light and SWE (i.e. monochromatic light of 410nm). Biopsies were taken as reference at the center of the imaged region and were scored for the Geboes score (GBS). The SWE-CAD output was displayed on the separate monitor of the bedside module as a blue or red-colored indication, corresponding to histological remission or non-remission, respectively. Each region (2 in rectum and 2 in sigmoid) was simultaneously scored for MES by the endoscopist. Results In a total of 36 patients histological disease activity was automatically scored using the SWE-CAD. On a section level this CAD-system showed an accuracy of 96.4%, corresponding sensitivity was 99.3% and specificity was 85.5%. When differentiating for disease activity as mild, moderate and severe, accuracy was 97.7%, 62.8% and 95.0%, respectively. On a per-patient level, overall diagnostic accuracy remained high with 94.4%, with only 2/36 underestimations when compared to GBS. Conclusion In this pilot trial, we successfully tested a novel CAD-system, utilizing SWE technology, for real-time assessment of histological disease activity in patients with UC. The system demonstrated exceptional clinical accuracy at 94.4% per-patient level, potentially aiding physicians in interpreting subtle endoscopic abnormalities, leading to cost-effective and individualized patient management.

Diagnosis and Pharmacological Management of Microscopic Colitis in Geriatric Care.

Microscopic colitis, a diagnosis under the umbrella term of inflammatory bowel disease, is a prevalent cause of watery diarrhea, often with symptoms of urgency and bloating, typically observed in older adults aged ≥60years. Its incidence has been reported to exceed those of ulcerative colitis and Crohn's disease in some geographical areas. Although nonpathognomonic endoscopic abnormalities, including changes of the vascular mucosal pattern; mucosal erythema; edema; nodularity; or mucosal defects, e.g., "cat scratches" have been reported, a colonoscopy is typically macroscopically normal. As reliable biomarkers are unavailable, colonoscopy using random biopsies from various parts of the colon is compulsory. Based on the histological examination under a microscope, the disease is divided into collagenous (with a thickened subepithelial collagenous band) and lymphocytic (with intraepithelial lymphocytosis) colitis, although incomplete forms exist. In routine clinical settings, the disease has a high risk of being misdiagnosed as irritable bowel syndrome or even overlooked. Therefore, healthcare providers should be familiar with clinical features and rational management strategies. A 6-8-week oral budesonide treatment course (9 mg/day) is considered the first-line therapy, but patients often experience relapse when discontinued, or might become intolerant, dependent, or even fail to respond. Consequently, other therapeutic options (e.g., bismuth subsalicylate, biologics, loperamide, bile acid sequestrants, and thiopurines) recommended by available guidelines may be prescribed. Herein, clinically meaningful data is provided based on the latest evidence that may aid in reaching a diagnosis and establishing rational therapy in geriatric care to control symptoms and enhance the quality of life for those affected.

Natural Histories and Disease Complications in a Cohort of 151 Children With Gastric or Duodenal Eosinophilia.

Eosinophilic gastritis (EoG) and duodenitis (EoD) are rare conditions that are poorly understood. Our aim was to describe the natural history of children with varying degrees of gastric or duodenal eosinophilia with respect to disease complications and histologic and endoscopic longitudinal trajectories. The electronic medical record at a tertiary children's hospital was queried to identify patients with EoG, EoD, or EoG + EoD who were cared for between January 2010 and 2022. Multiple logistic regression was performed to explore associations between baseline features and persistence/recurrence of eosinophilia or complications remote from diagnosis. We identified 151 patients: 92 with EoG, 24 with EoD, 12 with EoG + EoD, and 23 with tissue eosinophilia but did not meet histologic criteria for EoG or EoD (low grade). The average age at diagnosis was 10.6 years, and average follow-up was 5.8 years. Twenty-five percent of patients with EoG or EoD had persistence/recurrence of eosinophilia; this was associated with increases in the EoG Endoscopic Reference Score (adjusted odds ratio [aOR] 1.34, confidence interval [CI] 1.03-1.74) on diagnostic endoscopy. Eighteen percent suffered from disease complications, and development of late complications was associated with presenting with a complication (aOR 9.63, CI 1.09-85.20), severity of duodenal endoscopic abnormalities (aOR 8.74, CI 1.67-45.60), and increases in the EoG Endoscopic Reference Score (aOR 1.70, CI 1.11-2.63). Patients with gastric and duodenal eosinophilia should be followed closely to monitor for recurrence and complications, especially those presenting with endoscopic abnormalities or complications.

Which Alarm Symptoms Are Associated With Abnormal Gastrointestinal Endoscopy Among Thai Children?

Alarm symptoms (red flag signs) are crucial indications for management decisions on pediatric gastrointestinal endoscopy. We aimed to identify items in the alarm symptoms and pre-endoscopic investigations that predict abnormal endoscopy results. A retrospective descriptive study was conducted among children aged under 18 years undergoing endoscopy. The patients were classified into normal and abnormal endoscopic groups. The incidence of alarm symptoms and pre-endoscopic investigations were compared between the groups. Univariate and multivariate logistic regression analyses were performed to determine independent risk factors for abnormal endoscopy. Of 148 participants, 66 were classified in the abnormal endoscopy group. Compared with the normal group, the abnormal group had a significantly higher prevalence of alarm symptoms. Moreover, hematemesis/hematochezia, anemia, low hemoglobin level, hypoalbuminemia, rising erythrocyte sedimentation rate, increased serum lipase, and blood urea nitrogen/creatinine ratio were significantly higher in the abnormal endoscopy group than in the normal group. Multivariate logistic regression analysis indicated that hematemesis/hematochezia and low hemoglobin level were independent risk factors for abnormal endoscopy. The alarm symptoms and pre-endoscopic investigations were evaluated using predictive factors for abnormal pediatric endoscopic findings. According to multivariate logistic regression analysis, hematemesis/hematochezia and low hemoglobin levels were independent risk factors for abnormal endoscopy.

Real time anatomical landmarks and abnormalities detection in gastrointestinal tract.

Gastrointestinal (GI) endoscopy is an active research field due to the lethal cancer diseases in the GI tract. Cancer treatments result better if diagnosed early and it increases the survival chances. There is a high miss rate in the detection of the abnormalities in the GI tract during endoscopy or colonoscopy due to the lack of attentiveness, tiring procedures, or the lack of required training. The procedure of the detection can be automated to the reduction of the risks by identifying and flagging the suspicious frames. A suspicious frame may have some of the abnormality or the information about anatomical landmark in the frame. The frame then can be analysed for the anatomical landmarks and the abnormalities for the detection of disease. In this research, a real-time endoscopic abnormalities detection system is presented that detects the abnormalities and the landmarks. The proposed system is based on a combination of handcrafted and deep features. Deep features are extracted from lightweight MobileNet convolutional neural network (CNN) architecture. There are some of the classes with a small inter-class difference and a higher intra-class differences, for such classes the same detection threshold is unable to distinguish. The threshold of such classes is learned from the training data using genetic algorithm. The system is evaluated on various benchmark datasets and resulted in an accuracy of 0.99 with the F1-score of 0.91 and Matthews correlation coefficient (MCC) of 0.91 on Kvasir datasets and F1-score of 0.93 on the dataset of DowPK. The system detects abnormalities in real-time with the detection speed of 41 frames per second.

Proton Pump Inhibitors Modulate Gene Expression Profile in Esophageal Mucosa and Microbiome.

Proton pump inhibitors (PPIs) are commonly used to manage children with upper gastrointestinal symptoms and without a formal diagnosis. We investigated the effect of PPIs on esophageal mucosal transcriptome and active microbiota in children with normal esophagi. Furthermore, we examined whether the differences in host esophageal mucosal gene expression were driven by an underlying esophageal epithelial cell type composition. Using metatranscriptomics, the host transcriptional and active microbial profiles were captured from 17 esophageal biopsy samples (PPI naïve [PPI-], n = 7; PPI exposed [PPI+], n = 10) collected from children without any endoscopic and histologic abnormalities in their esophagus (normal esophagus). Deconvolution computational analysis was performed with xCell to assess if the observed epithelial gene expression changes were related to the cell type composition in the esophageal samples. The median (IQR) age of our cohort was 14 years (12-16) with female (63%) preponderance. Both groups were similar in terms of their demographics and clinical features. Compared with PPI-, the PPI+ had upregulation of 27 genes including the MUC genes. The cell type composition was similar between the PPI- and PPI+ groups. Prevotella sp and Streptococcus sp were abundant in PPI+ group. In children with normal esophagus, PPI exposure can be associated with upregulation of esophageal mucosal homeostasis and epithelial cell function genes in a cell-type independent manner, and an altered esophageal microbiome. Additional studies are warranted to validate our findings and to investigate the causal effect of PPIs on the normal esophageal epithelium and microbial communities.

Diagnostic yield of random colon biopsy sampling in patients with chronic diarrhea and normal colonoscopy: a systematic review and meta-analysis

Background and AimsMost colonoscopy examinations in patients with chronic unexplained diarrhea do not reveal endoscopic abnormalities, and routine random colon biopsy specimens are taken for further diagnostic assessment. In this study, we aimed to perform a systematic review and meta-analysis to study the pooled diagnostic value of random colon biopsy sampling in this patient population.MethodsMultiple databases (MEDLINE, Scopus, Embase) were searched in May 2022 for studies evaluating the diagnostic yield of random biopsy sampling in patients with chronic diarrhea with normal colonoscopy examinations. Standard meta-analysis methods used the random-effects model, and heterogeneity was assessed using the I2 statistics.ResultsTwenty-one studies were included in the study (3322 patients). The pooled rate of normal colon biopsy sampling was 48% (95% confidence interval [CI], 31-65.2; I2 = 98%), and normal ileal biopsy sampling was 88.5% (95% CI, 51.3-98.3; I2 = 93%). The pooled rate of significant histopathologic change was 30% (95% CI, 20-41; I2 = 96%). The pooled rates of specific diagnoses based on random colon biopsy sampling were as follows: microscopic colitis, 15% (95% CI, 10-21; I2 = 92%); lymphocytic colitis, 9% (95% CI, 6 -13; I2 = 85%); collagenous colitis, 3.5% (95% CI, 2.4-5.7; I2 = 80%); nonspecific colitis, 20% (95% CI, 11-32.8; I2 = 97%); inflammatory bowel disease, 1.7% (95% CI, .8-3.5; I2 = 54%); and eosinophilic colitis, 2.3% (95% CI, 1.1-4.5; I2 = 69%).ConclusionsThis meta-analysis of 21 studies demonstrated significant histopathologic change in 30% and microscopic colitis in 15%. Normal colon biopsy sampling was noted in 48% and normal ileum biopsy sampling in 88.5%. Ileal biopsy data were based on limited data and studies (only 3 included). In studies with a mean patient age <49 years, 40% demonstrated significant histopathologic changes. Most colonoscopy examinations in patients with chronic unexplained diarrhea do not reveal endoscopic abnormalities, and routine random colon biopsy specimens are taken for further diagnostic assessment. In this study, we aimed to perform a systematic review and meta-analysis to study the pooled diagnostic value of random colon biopsy sampling in this patient population. Multiple databases (MEDLINE, Scopus, Embase) were searched in May 2022 for studies evaluating the diagnostic yield of random biopsy sampling in patients with chronic diarrhea with normal colonoscopy examinations. Standard meta-analysis methods used the random-effects model, and heterogeneity was assessed using the I2 statistics. Twenty-one studies were included in the study (3322 patients). The pooled rate of normal colon biopsy sampling was 48% (95% confidence interval [CI], 31-65.2; I2 = 98%), and normal ileal biopsy sampling was 88.5% (95% CI, 51.3-98.3; I2 = 93%). The pooled rate of significant histopathologic change was 30% (95% CI, 20-41; I2 = 96%). The pooled rates of specific diagnoses based on random colon biopsy sampling were as follows: microscopic colitis, 15% (95% CI, 10-21; I2 = 92%); lymphocytic colitis, 9% (95% CI, 6 -13; I2 = 85%); collagenous colitis, 3.5% (95% CI, 2.4-5.7; I2 = 80%); nonspecific colitis, 20% (95% CI, 11-32.8; I2 = 97%); inflammatory bowel disease, 1.7% (95% CI, .8-3.5; I2 = 54%); and eosinophilic colitis, 2.3% (95% CI, 1.1-4.5; I2 = 69%). This meta-analysis of 21 studies demonstrated significant histopathologic change in 30% and microscopic colitis in 15%. Normal colon biopsy sampling was noted in 48% and normal ileum biopsy sampling in 88.5%. Ileal biopsy data were based on limited data and studies (only 3 included). In studies with a mean patient age <49 years, 40% demonstrated significant histopathologic changes.

Characterization of a group of children with eosinophilic esophagitis in Cali, Colombia.

Eosinophilic esophagitis (EoE) is an immunologically mediated chronic disease of the gastrointestinal tract. The objective of this study was to clinically and demographically describe a child population with EoE diagnosed in a high-complexity hospital in Cali, Colombia. A retrospective study was carried out. The clinical histories of patients between 0 and 18 years with clinical suspicion and a histological diagnosis of EoE were analyzed. All patients underwent an allergy study, either by measurement of specific immunoglobulin (Ig) E and/or an intraepidermal skin-prick test. Thirty-five patients were included in the study, of which 21 (60%) women. The median age was 8 years (interquartile range [IQR] 5-12), and the age of onset of symptoms was 5 years (IQR 2-10). Thirty patients (85.7%) reported a history of allergic disease, with rhinitis being the most frequent (n = 25, 71.4%). Only one patient reported with food allergy mediated by IgE. The main symptoms in patients included abdominal pain (17 [48.6%]), refractory gastroesophageal reflux (16 [45.7%]), and choking (9 [25.7%]). Upper gastrointestinal endoscopy was normal in 10 patients (38.5%). The median number of eosinophils in the biopsy was 42 (IQR 31-92). Allergenic sensitization was verified in 25 of 35 patients (71.4%). Of these, dust mite allergy was positive in 21 patients (84%), while the most frequent food allergy was toward cow's milk, in five patients (31.3%). The majority of patients with EoE were females. The most frequent symptom was abdominal pain. Endoscopic abnormalities were also observed frequently, and the prevalence of other allergic diseases (especially rhinitis) and allergenic sensitization (especially to mites) was high.