Achalasia is an uncommon primary esophageal motility disorder characterized by impaired relaxation of the lower esophageal sphincter and esophageal body peristalsis, with a rising prevalence among the elderly due to global population aging. This review summarizes the current evidence on the clinical presentation, diagnostic algorithm, and management of achalasia in geriatric patients. A literature search was conducted focusing on age-related differences in symptoms, endoscopic and functional testing, and outcomes of available therapeutic modalities. Clinical presentation of achalasia differs among younger and geriatric patients, with the latter presenting less pronounced symptoms. Geriatric patients experience a higher risk of malnutrition and aspiration and exhibit more often advanced disease stages, including sigmoid esophagus. High-resolution manometry represents the gold standard for diagnosis, and upper gastrointestinal endoscopy should precede it in order to exclude causes of mechanical obstruction. The treatment remains non-causative and encompasses botulinum toxin injection, pneumatic dilation, peroral endoscopic myotomy, and laparoscopic Heller's myotomy with fundoplication. Considering the evolving potential of minimally invasive techniques, advanced age should not be regarded as a contraindication for the definitive treatment of achalasia, and evidence-based, age-specific recommendations should be developed for optimizing clinical outcomes.

Safe and effective sedation are important factors when performing gastrointestinal endoscopy. However, clinicians should be cautious when using sedatives in older patients because of their decreased physiological reserves. Remimazolam is an ultrashort active benzodiazepine that has attracted attention because of its efficacy. This study aimed to determine the safety and efficacy of remimazolam compared with midazolam as a sedative for diagnostic upper gastrointestinal endoscopy in older patients aged ≥ 65 years. We randomly assigned patients aged ≥ 65 years who were scheduled for diagnostic upper gastrointestinal endoscopy. The average induction time, average recovery time, and side effect profile of patients who received remimazolam as a sedative were compared with those of patients who received midazolam. A total of 120 patients underwent randomization (60 in the remimazolam group and 60 in the midazolam group). Patients who received remimazolam had shorter average induction (mean ± standard deviation, 102.0 ± 77.2s vs. 327.5 ± 125.3s, p < 0.001) and recovery times (mean ± standard deviation, 5.8 ± 3.1min vs. 13.4 ± 7.8min, p < 0.001) than those who received midazolam. No significant difference in side effect profiles was observed between the groups. In performing upper gastrointestinal endoscopy in older patients, remimazolam can be a good alternative sedative to midazolam, whether used as monotherapy or in combination therapy.

This study aimed to evaluate the relationship between Helicobacter pylori infection and duodenal eosinophil-mast cell counts in dyspeptic patients with a history of drug allergy compared to those without such a history. A total of 88 dyspeptic patients with a history of drug allergy and 88 dyspeptic patients without a history of drug allergy (control group), who presented to our internal medicine and gastroenterology clinics, were included in the study. The demographic characteristics, laboratory findings, gastric-duodenal endoscopic findings and biopsy samples obtained via upper gastrointestinal endoscopy were retrospectively compared between the 2 groups. Statistical analysis was performed on the demographic, laboratory, endoscopic and histopathological data of both groups. There was no statistically significant difference between the groups in terms of age and gender parameters (P > .05). However, lymphocyte levels were found to be significantly higher in the group with a history of drug allergy compared to the control group (P = .035 and P = .018, respectively). The presence of H pylori infection, gastric atrophy, and duodenal eosinophil-mast cell counts were significantly higher in the drug allergy group compared to the control group (P < .05). No statistically significant differences were found between the groups in terms of intestinal metaplasia, gastric dysplasia, gastric edema/hyperemia, and duodenal edema/hyperemia (P > .05). The history of drug allergy should be considered in the management of dyspeptic patients. Further large-scale, multicenter, randomized controlled studies are warranted in this area.

Dumping Syndrome (DS) and Reactive Hypoglycaemia (RH) are common occurrences post bariatric surgery, particularly post Roux-En-Y Gastric Bypass (RYGB). We present our initial results using Transoral Outlet Reduction Endoscopy (TORE) in the management of patients who failed to respond to dietary and medical treatment for DS. All patients identified to have symptoms consisting with DS were discussed in the complex bariatric MDT and assessed for suitability of TORE via an upper gastro-intestinal endoscopy to assess the length of the pouch, size of the gastro-jejunostomy and the presence of alternative pathologies. Since the onset of our TORE services in January 2025, we identified 17 patients for treatment with TORE. The median age was 45yrs (IQR 36-55). Sixteen patients (94%) were women and all patients scored ≥ 7 on the Sigstad scoring questionnaire. Two patients had previously undergone conversion of gastric sleeve to a RYGB whilst all others had a primary RYGB. 2 patients were found to have unfavourable anatomy and was not safe to proceed with the procedure whilst one patient was followed up privately hence no data were available for review. The data showed a complete response to treatment at 2years for 66% of patients. Four patients did not respond to treatment with TORE and are being considered for surgical intervention. TORE is an effective treatment for patients with DS not responsive to medical and dietary therapy. We believe it is an effective non-surgical treatment method prior to considering reversal of the original surgery (RYGB) with its associated weight regain. Further work is planned to assess its outcomes in larger groups of patients.

Abstract Acute arsenic poisoning, a life-threatening condition, results from exposure to inorganic arsenic compounds such as arsenic trioxide (As2O3). This case report describes a 27-year-old male who ingested 25 g of As2O3 and presented with severe gastrointestinal (GI) toxicity and acute kidney injury. Management involved airway protection, GI decontamination with activated charcoal, chelation therapy using D-penicillamine, and supportive care including N-acetylcysteine (NAC) and dialysis for renal failure. GI endoscopy revealed diffuse mucosal ulceration consistent with arsenic’s corrosive effects. The patient recovered following three sessions of sustained low-efficiency dialysis and was discharged with improved renal function. This case highlights the critical role of prompt supportive management, chelation, and hemodialysis in arsenic poisoning. It also highlights novel use of NAC as an adjunctive therapy and the importance of monitoring multi-organ involvement for improved outcomes.

Propofol is the most commonly used intravenous anesthetic for endoscopic surgery, although it comes with various adverse effects. Research indicates that Remimazolam, which is considered a safe general anesthetic, is being increasingly adopted as an alternative to propofol in clinical settings. Our meta-analysis sought to evaluate whether the rate of adverse reactions associated with Remimazolam in gastrointestinal endoscopic procedures is acceptable, and whether its surgical success rate is at least comparable to that of propofol. Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we searched five electronic databases (PubMed, Scopus, Cochrane Library, Embase, and Web of Science) to identify eligible studies published up to January 2025. Using R version R.4.4, we reported outcomes as risk ratios (RRs) or mean differences (MDs) and confidence intervals (CIs). A P-value of ≤ 0.05 is considered statistically significant. Our meta-analysis included 37 studies encompassing 8533 patients. The results, analyzed using a random effects model, demonstrated no statistically significant difference in induction time between the two sedative groups, with an overall MD of 0.11min (95% [- 0.10; 0.31], p = 0.2977). Patients in the Remimazolam group experienced longer total sedation times than those receiving Propofol, with an MD of 1.84 min (95% CI [0.61; 3.07], p = 0.0033). The pooled analysis indicated low heterogeneity (I2 = 4.2%). There was no statistically significant difference between the two sedatives in procedure time, with an MD of 0.16 (95% CI: [-0.13; 0.45], p = 0.2689). The pooled analysis displayed moderate heterogeneity (I2 = 43.5%, p = 0.0052). Remimazolam has demonstrated safety, showing a reduced incidence of hypotension, bradycardia, respiratory depression, and hypoxemia compared to propofol. However, efficacy outcomes including the induction time and total procedure time were comparable between the two groups. However, the results were heterogeneous, which could be due to variability in the perfumed procedures, co-analgesics or dosing.

Automatic processing of gastrointestinal endoscopy referrals and patient instructions using large language models.

To compare the incidence of hypoxia and other sedation-related adverse events (AEs) in overweight patients undergoing gastrointestinal (GI) endoscopy who were sedated using ciprofol or propofol. A randomized, controlled trial was conducted in five hospitals in China between September 2022 and August 2023. Patients were randomized into either ciprofol or propofol sedation. The primary outcome was the total incidence of hypoxia and severe hypoxia. The secondary outcomes were hypoxia incidence, severe hypoxia incidence, subclinical respiratory depression incidence, endoscopy success rate, injection pain incidence, and corrective hypoxic measures proportion. A total of 1018 patients were randomized into either ciprofol group (n = 506) or propofol group (n = 512). The mean BMI was 26.23 kg/m2 in the ciprofol group and 26.17 kg/m2 in the propofol group. Compared with propofol, ciprofol showed lower incidences of total hypoxia and severe hypoxia in both the full analysis set (FAS) and per-protocol analysis set (PPS). The lower incidence was particularly significant for severe hypoxia (4.35% vs. 7.62%, p = 0.028 in FAS). The injection pain incidence was significantly lower in the ciprofol group than in the propofol group (2.57% vs. 13.28%, p < 0.001 in FAS). Moreover, fewer patients in the ciprofol group required oxygen-correction therapy (20.40% vs. 25.70%, p = 0.047 in PPS), and ciprofol had a lower incidence of AEs associated with sedation. During GI endoscopy, overweight patients are significantly less prone to hypoxia when sedated with ciprofol than with propofol, offering a safer alternative. ClinicalTrials.gov (NCT05518929).

To evaluate the diagnostic performance of multiple digestive enzyme biomarkers in detecting and characterizing laryngopharyngeal reflux disease (LPRD). Patients with LPRD at the 24-h hypopharyngeal-esophageal multichannel intraluminal impedance-pH testing (HEMII-pH) were consecutively recruited from January 2020 to May 2024 from two European hospitals. The control group consisted of adults without symptoms. Prospective clinical data collection included demographics, gastrointestinal endoscopy, HEMII-pH, reflux symptom score (RSS), and reflux sign assessment (RSA) findings. At baseline, pepsin, elastase, cholesterol, bile acids, trypsin, pancreatic, and gastric lipase were measured in saliva samples of LPRD patients and asymptomatic individuals. Sensitivity, specificity, positive and negative predictive values, and diagnostic accuracy (receiver operating characteristic (ROC) curve and area under the curve (AUC)) were evaluated. One hundred and twenty-three patients and forty-eight asymptomatic individuals were prospectively recruited. Patients exhibited significantly elevated salivary pH and elastase levels, but decreased cholesterol compared to controls. Salivary cholesterol demonstrated superior diagnostic performance (AUC = 0.989), with a 2.05 mg/dL threshold yielding excellent sensitivity (100%), specificity (94.3%), and predictive values. Elastase showed moderate-to-high diagnostic performance (AUC = 0.811, threshold > 49.2 μg/mL). Combined RSS > 13 and salivary pH demonstrated robust diagnostic accuracy (SE = 88.8%, SP = 97.1%). Cholesterol positively correlated with 3-month RSS (r = 0.538). Salivary cholesterol, elastase, and the salivary pH emerge as promising diagnostic biomarkers for LPRD, demonstrating superior accuracy to other digestive enzymes and potential value in predicting treatment outcomes. III.

The no-show rate in gastrointestinal (GI) endoscopy is a relevant phenomenon. A "no-show" event is defined as a scheduled procedure for which the patient did not show up. It is often associated with worse health outcomes and is a predictor of higher subsequent acute care utilization. The aim of this study is to highlight which strategies are most effective in preventing "no-shows" in a GI endoscopy unit. Following PRISMA guidelines for reporting, a narrative review of the literature was performed. Articles were retrieved from PubMed, Scopus, and CINAHL. The review process selected 7 articles meeting the inclusion criteria. This review suggests that an educational telephone intervention by endoscopy nurses decreases the no-show rate, facilitates compliance with exam preparation protocols (colonoscopy in particular), decreases patient anxiety, and results in a beneficial economic outcome for the organization.

Upper gastrointestinal endoscopy (UGIE) is a widely used procedure for the diagnosis and treatment of upper gastrointestinal diseases. The use of lidocaine as a topical pharyngeal anesthetic has been shown to facilitate endoscopy intubation and reduce pharyngeal mucosa injury. Lidocaine gel and spray are two common forms of topical pharyngeal anesthesia used to reduce discomfort and pain during these procedures. In This prospective, randomized, single-blinded clinical trial, 180 patients eligible for UGIE were randomly allocated into 2 groups. The first Group S (Lidocaine Spray) received 6 puffs of 10% lidocaine spray each puff delivering 10mg of lidocaine, sprayed to the pharynx distributed as 2 puffs in left, right and middle portion after tongue depression in 2 consecutive 30-second intervals. After each spray, patients were asked to swallow to maximize the anesthetic effect on the hypopharynx. The second Group G (Lidocaine Gel) received 10g of 2% lidocaine gel (gently applied 3-5 minutes before the endoscopy at three consecutive 30-second intervals on the palate and peritonsillar areas. Patients were informed to spread the gel within their mouth by the tongue and then swallow it to cover the oropharynx and esophagus. Outcome parameters included incidence of gag reflex as a primary outcome with the ease of esophageal entrance during endoscopy were com-pared. onset of numbness, Total propofol consumption, recovery time, Endoscopist and Patient Satisfaction and complications as a secondary outcome during UGIE. Comparison between the groups studied regarding the outcome parameters. The Lidocaine gel groups achieved better performance and better scores in reducing gag reflex (6.67%) compared to (21.11%) Spray group, and ease of 1st attempt esophageal intubation is statisti-cally significant better (96.67%) compared to (85.56%) in spray group as well as reducing total patient number of propofol needs 8/90 (8.89%) compared to 23/90 (25.56%) in Spray group as well as increase patient and endoscopist satisfaction. Lidocaine Gel is considered safe, suitable and effective option and exhibiting better performance in reducing the incidence of gag reflex, with the ease of esophageal entrance shortening recovery time and improving patient and endoscopist satisfaction. Decrease total propofol consumption in patients undergoing UGIE compared to lidocaine spray.

Performing endoscopic retrograde cholangiopancreatography (ERCP) procedures is associated with musculoskeletal (MSK) pain and injury in physicians. Previous studies have explored MSK symptoms among those who assist with endoscopy in general; this study aims to describe the prevalence and predictors of MSK pain and injury specifically among nurses and technicians who assist with ERCP. An anonymous electronic survey was distributed to nurses and technicians involved in ERCP procedures at institutions affiliated with the American Society of Gastrointestinal Endoscopy. Out of 150 respondents, 92.7% reported experiencing at least one MSK symptom, with 61.5% attributing these symptoms to assisting with ERCP. Additionally, 36% reported a diagnosis of MSK conditions, including carpal tunnel syndrome (13.33%), lumbar radiculopathy (7.33%), and De Quervain's tenosynovitis (6%). Only 20% of participants received prior training on ergonomics in endoscopy; 80.7% of the participants expressed interest in injury prevention training. Most of those surveyed report an MSK pain symptom, with more than half attributing this pain to assisting with ERCP procedures. Future studies into specific risk factors for MSK pain and injury in nurses and technicians are advised and can inform policies and procedures for preventing injury.

Enhancing gastroenterology education through e-learning.

Evaluation of gastrointestinal biopsies with two-slide serial sections: Analysis of 1715 cases with emphasis on clinical impact.

Introduction: Hypoxia is a common complication during upper gastrointestinal endoscopyunder deep sedation. While simple nasal cannulas are commonly used for oxygen delivery, high-flow nasal cannulas (HFNC) provide higher oxygen levels, generate positive pressure, and reduce dead space. We hypothesize that HFNC reduces the risk of hypoxia compared to simple nasal cannulas in these procedures. Methods: This was prospective, comparative observational study conducted in a tertiary care center of Nepal with the primary objective to compare the rates of hypoxia (SpO2 &lt; 92%) and secondary objectives were to compare interruption of procedure due to hypoxia, the lowest oxygen level recorded and episodes of hypoxia between high flow nasal cannula (flow rate of 30l/min with FiO2 of 0.5) and simple nasal cannula (flow rate of 6l/min) in patients undergoing upper gastrointestinal endoscopic procedures in deep sedation using propofol infusion. Results: A total of 112 patients were enrolled, with 56 receiving oxygen via simple nasal cannula (SNC) and 56 via high-flow nasal cannula. Hypoxia occurred significantly more in the SNC group compared to the HFNC group (37.50% vs. 16.07%, p=0.01). Severehypoxia was also more frequent with SNC (16.07% vs. 5.36%). Multiple hypoxia episodes were observed only in the SNC group (8.93% vs. 0%). Procedure abandonment was higher in the SNC group (7.14% vs. 1.79%). Conclusion: The use of high flow nasal cannula reduces the incidence of hypoxia in patients undergoing upper gastrointestinal endoscopic procedures with deep sedation compared to simple nasal cannula.

A 10-year-old, male castrated, mixed-breed dog presented with a four-month history of enteropathy unresponsive to standard treatment. Initial bloodwork ruled out non-gastrointestinal illness and abdominal ultrasound revealed stratified segmental small intestinal muscularis thickening. Gastrointestinal endoscopy and biopsy identified duodenal carcinoma with lymphatic infiltration. Due to the absence of an identified gross lesion, nascent primary duodenal carcinoma was suspected. The dog presented 29 days later for acute worsening of signs, development of neoplastic peritoneal effusion, and protein-losing enteropathy. Thoracic radiographs identified pulmonary nodules consistent with carcinoma on cytology. Humane euthanasia was elected 2 days later with necropsy identifying disseminated neoplastic emboli and marked lipogranulomatous lymphangitis. Strong positive nuclear labelling for thyroid transcription factor-1 of the pulmonary neoplasm and neoplastic cells within the small intestinal lymphatics of the original biopsy were consistent with disseminated primary pulmonary carcinoma (PPC). This is the first report describing disseminated PPC presenting primarily with gastrointestinal signs.

Patient: Male, 74-year-oldFinal Diagnosis: Isolated hepatic hemangiomatosisSymptoms: Anemia • coagulopathy • liver failure • thrombocytopeniaClinical Procedure: —Specialty: Gastroenterology and HepatologyObjective: Unknown etiologyBackgroundThe most common vascular lesions of the liver are hepatic hemangiomas (HH), which are generally asymptomatic and do not require medical intervention. However, when the lesions are large or multiple, they can be a significant clinical problem. This report describes a unique case of an elderly patient with isolated hepatic hemangiomatosis associated with the onset of consumptive coagulopathy and hemolytic anemia, ultimately resulting in liver failure and death.Case ReportA 74-year-old man presented with jaundice, progressive weight loss, fatigue, lower-limb edema, and recurrent epistaxis. Laboratory findings revealed normocytic anemia, thrombocytopenia, hyperbilirubinemia, hypoalbuminemia, and elevated liver enzymes. Abdominal ultrasound (US) and computed tomography (CT) demonstrated hepatomegaly with multiple hypoechoic and hypodense focal lesions, initially raising suspicion of metastatic disease. Colonoscopy and upper gastrointestinal endoscopy showed no evidence of malignancy. A core-needle biopsy of the hepatic lesions, complemented by positron emission tomography–computed tomography (PET-CT) and magnetic resonance imaging (MRI), confirmed the benign nature of the lesions, consistent with isolated hepatic hemangiomatosis.The patient was managed symptomatically and discharged home with recommendations for continued outpatient monitoring and urgent consultation in the event of any clinical deterioration. Unfortunately, after 3 months of relative symptoms improvement, he developed gastrointestinal bleeding and acute liver failure, which ultimately resulted in his death.ConclusionsHepatic vascular lesions are diagnostically challenging; definitive diagnosis requires correlation of clinical, imaging, and histopathological findings, as well as multidisciplinary consultation. The clinical course of hepatic hemangiomatosis ranges from benign to life-threatening, with potential complications such as hepatic failure or coagulopathy.

Ampullary neuroendocrine tumors (NETs) are extremely rare, representing 0.3%-1% of gastrointestinal NETs and less than 2% of periampullary cancers. Due to their rarity, there is limited data on their natural history, management, and outcomes. Current European Neuroendocrine Tumor Society guidelines (2023) recommend pancreaticoduodenectomy (PD) as the standard treatment. However, this approach is invasive and associated with high morbidity and mortality. Emerging evidence suggests that endoscopic papillectomy (EP) could be a viable alternative in selected cases. This retrospective multicenter study aimed to evaluate the feasibility and outcomes of endoscopic resection for ampullary NETs. This retrospective case series included 14 patients who underwent EP for ampullary NETs between 2011 and 2022 across three Italian tertiary centers. Pre-procedural evaluation was performed following European Society of Gastrointestinal Endoscopy guidelines. Endoscopic papillectomy was performed under monitored sedation, using standard snares for en bloc resection. Follow-up endoscopy was conducted at a median of 3 months. Primary outcomes included complete resection (R0) and recurrence rates; secondary outcomes focused on adverse events. Fourteen patients (median age: 62.5 years; 50% male) were included. Median tumor size was 18 mm. In 12 out of 14 cases, ampullary NETs were diagnosed only after endoscopic resection. Post-resection histology identified 8 G1 NETs (Ki-67 1%) and 6 G2 NETs (Ki-67 5%). Complete resection was achieved in 11 cases (78.6%). Among 3 incomplete resections, 2 were managed surgically, while 1 was followed up without recurrence. Residual disease was detected in 3 patients: 2 were managed endoscopically, and 1 required surgery. No recurrences occurred during a median follow-up of 14.5 months. Adverse events occurred in 42.9% of patients, including 5 cases of bleeding and 1 case of mild pancreatitis, all resolved without major sequelae. Median hospital stay was 2.5 days. Our findings suggest that EP offers a promising alternative to surgery in selected patients with ampullary NETs. Endoscopic resection was associated with high rates of R0 and favorable short-term outcomes, with effective endoscopic management of residual disease and procedure-related adverse events. Consistent post-procedural surveillance remains essential to detect residual or recurrent disease. Larger prospective studies are warranted to refine patient selection criteria, optimize protocols, and establish the long-term efficacy.

Comparative Efficacy and Safety of Remimazolam Versus Propofol for Sedation in Gastrointestinal Endoscopy: A Systematic Review and Meta-Analysis

Background/Objectives: Iron-deficiency anemia (IDA) is a common condition in children and is frequently attributed to nutritional causes. However, gastrointestinal (GI) pathology may be present even in the absence of overt GI symptoms. The diagnostic value of endoscopic evaluation in asymptomatic pediatric patients with IDA remains debated. This systematic review aimed to synthesize available evidence on endoscopic and histologic findings in asymptomatic children with IDA and to assess their clinical implications. Methods: A systematic review was conducted in accordance with the PRISMA 2020 guidelines, and the protocol was registered in PROSPERO. MEDLINE (via PubMed) and Scopus were searched for studies involving children and adolescents (0–18 years) with confirmed iron-deficiency anemia and no gastrointestinal symptoms who underwent endoscopic evaluation. Results: Six studies met the inclusion criteria, comprising a total of 455 pediatric patients. Upper GI endoscopy was the most commonly performed procedure. Clinically significant findings were frequently identified, including histologic features consistent with celiac disease, Helicobacter pylori-associated gastritis, and chronic inflammatory gastric changes. Histologic abnormalities were often present despite minimal or absent macroscopic endoscopic findings. The diagnostic yield of endoscopy was particularly high in older children and adolescents and in those with severe or refractory IDA. Conclusions: This systematic review demonstrates that asymptomatic children with IDA may harbor significant GI pathology detectable by endoscopic and histologic evaluation. These findings support the consideration of targeted endoscopic assessments in selected pediatric patients with unexplained or persistent IDA, even in the absence of GI symptoms.