BACKGROUND:Bowel urgency (BU) is a key symptom of ulcerative colitis (UC), often impairing the quality of life. This study aimed to identify intestinal ultrasound parameters associated with BU, given that UC may also have transmural involvement, and compare these with endoscopic activity and biomarkers. METHODS:In this single-centre prospective study, UC patients undergoing colonoscopy between January 31 and September 27, 2023 were enrolled. Transabdominal and transperineal ultrasound were performed to evaluate bowel wall thickness (BWT), including individual layers (mucosa, submucosa, and muscularis propria), and colour Doppler signal (CDS) in the sigmoid colon and rectum. BU was defined according to the Simple Clinical Colitis Activity Index urgency subscore. RESULTS:Of 59 patients, 33 (56%) reported BU. Compared with those without BU, patients with BU had significantly higher C-reactive protein, Mayo Endoscopic Subscore (MES), BWT (descending colon, sigmoid colon, rectum), CDS (sigmoid colon, rectum), and submucosal and muscularis propria thickness in the sigmoid colon (all p < 0.05). Mucosal thickness and faecal calprotectin were not significantly different (p = 0.11 and p = 0.48, respectively). In MES-adjusted logistic regression, submucosal (p < 0.01) and muscularis propria (p = 0.03) thickness remained associated with BU, whereas mucosal thickness did not (p = 0.97). Receiver operating characteristic analysis showed that sigmoid submucosal thickness had greater diagnostic accuracy than mucosal thickness (AUC 0.77 vs. 0.62, p < 0.05). CONCLUSIONS:Sigmoid submucosal thickening was associated with BU and suggests that transmural inflammation may contribute to symptom pathophysiology. TRIAL REGISTRATION:UMIN000050099.
BACKGROUND:The optimal timing of direct endoscopic necrosectomy (DEN) for Necrotizing Pancreatitis (NP) remains unclear. This meta-analysis aimed to evaluate the efficacy and safety of immediate DEN compared with on-demand DEN. METHODS:PubMed, Embase, Web of Science, and Cochrane Library databases were systematically searched to identify studies. The primary outcome measure was clinical success. RESULTS:Seven studies (4 RCTs and 3 observational studies) comprising 616 patients were included. Immediate DEN did not demonstrate a statistically significant advantage in clinical success (OR: 1.92, 95% CI 1.01-3.63). No significant differences were found in technical success (OR: 1.62, 95% CI: 0.43-6.09), total number of DEN (standardized mean difference: 0.31, 95% CI: -0.21-0.84), need for additional percutaneous drainage (OR: 0.53, 95% CI: 0.27-1.03), need for salvage surgery (OR: 0.60, 95% CI: 0.28-1.27), procedure-related adverse events were comparable between groups (OR: 0.81, 95% CI: 0.51-1.28), disease-related adverse events (OR: 0.84, 95% CI: 0.34-2.13), mortality (OR: 1.11, 95% CI: 0.47-2.59). In RCT-only analyses, these findings remained consistent. Immediate DEN lowered stent migration risk (OR: 0.31, 95% CI: 0.11-0.92), but lost significance in RCT-only analysis. CONCLUSION:This meta-analysis found no overall superiority of immediate DEN over on-demand DEN for patients with NP, highlighting the need to identify specific subgroups that benefit from an upfront necrosectomy strategy.
BACKGROUND:Family history of pancreatic cancer (PC), pathogenic germline variants (PGVs), and increased intrapancreatic fat (IPF) are individually associated with increased PC risk. Whether IPF is elevated in high-risk individuals (HRIs) with PC family history or PGVs is unknown. Although MRI is the preferred modality for IPF measurement, region-of-interest-based approaches are prone to sampling bias because pancreatic fat is heterogeneously distributed. We aimed to compare IPF among HRIs and matched non-HRI controls using an Artificial intelligence (AI)-based tool for whole pancreatic IPF measurement applied to magnetic resonance imaging (MRI). METHODS:We developed and validated a deep-learning pipeline for IPF measurement that incorporates automated pancreas segmentation on T1-weighted MRI images registered to the corresponding iterative decomposition of water and fat with echo asymmetry and least squares estimation images to compute IPF using proton density fat fraction (PDFF). This pipeline was used to quantify IPF and assess IPF distribution patterns in 85 HRIs and 170 non-HRIs matched 1:2 for age, sex, BMI, and diabetes status. A surface erosion approach was developed to minimize the impact of peripancreatic fat on IPF measurement. Linear models adjusting for matching variables were used to assess associations. RESULTS:Model-expert agreement for whole-pancreas PDFF was excellent (intraclass correlation coefficient 0.99; 95% CI, 0.98-0.99 mean absolute error 1.4%). Mean PDFF did not differ between HRIs and controls (25.8% [11.5] vs. 26.9% [11.4]; p = 0.32). PDFF increased with age (p = 0.015), male sex (p < 0.001), presence of diabetes (p = 0.009), BMI (p < 0.001). IPF distribution patterns did not differ by risk group. CONCLUSION:An AI-based approach provides accurate, scalable, and objective assessment of IPF quantity and distribution. IPF quantity and spatial distribution do not appear to differ based on germline or familial predisposition to PC.
BACKGROUND:Laparoscopic cholecystectomy is the standard treatment for acute cholecystitis (AC), but some patients are unfit for (immediate) surgery. Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) using a lumen-apposing metal stent (LAMS) is increasingly used in this population. OBJECTIVE:This multicenter cohort study aimed to evaluate practice patterns in EUS-GBD across Western centers and to identify factors that influence outcomes. DESIGN:We retrospectively analyzed data from patients undergoing EUS-GBD for AC across 18 centers. Patient-related, procedural and outcome data were collected. The primary outcomes of interest were LAMS-related adverse events (AEs), recurrent biliary disease, recurrent acute cholecystitis, and all-cause mortality. Time-to-event analyses were performed using center-stratified Cox proportional hazards and Fine-Gray competing-risk models to identify LAMS procedural factors associated with clinical outcomes. RESULTS:We included 496 patients with a median follow-up of 176 days (IQR 44-569). Technical and clinical success rates of EUS-GBD were 98.2% and 93.5%, respectively. LAMS-related AEs and recurrent biliary disease occurred in 11.1% and 18.8% of patients, respectively. Transduodenal access was associated with a lower cumulative incidence of LAMS-related AEs compared with transgastric access (SHR 0.42, 95% CI 0.23-0.76, p = 0.004) and lower rates of recurrent biliary disease and recurrent acute cholecystitis during follow-up. Larger LAMS diameters (> 10 mm) were associated with a lower risk of recurrent acute cholecystitis and all-cause mortality. No association between coaxial DPPS placement and improved long-term outcomes could be demonstrated after competing-risk adjustment. Among patients undergoing interval cholecystectomy (N = 46), LAMS-related conversion from laparoscopy to laparotomy occurred in 3 cases (6.5%). CONCLUSIONS:In this large cohort study, transduodenal access route and choice of a large (> 10 mm) LAMS diameter were associated with improved outcomes of EUS-GBD. EUS-GBD may be a feasible option as a bridge to laparoscopic cholecystectomy, with limited risk of conversion to laparotomy. The findings of our study require prospective validation.
BACKGROUND:Endoscopy with histopathological assessment of esophageal biopsies is the cornerstone for the diagnosis and phenotypic characterization of eosinophilic esophagitis (EoE). OBJECTIVE:To evaluate temporal trends in endoscopic assessment and biopsy sampling practices for EoE in a large European cohort and their association with temporal trends in diagnostic delay (DD). METHODS:A cross-sectional analysis was conducted using multicenter data from the EoE CONNECT registry. Endoscopic findings and biopsy data at diagnosis were analyzed. Temporal trends in biopsy strategies, EREFS implementation, and DD were assessed. Diagnostic sensitivity of individual esophageal segments and their combinations was evaluated in patients undergoing multi-segment sampling. Associations between guideline publication and biopsy practices were analyzed using logistic regression models. RESULTS:A total of 3298 patients were included. Biopsies were obtained from one esophageal segment in 12.6% of patients, two segments in 63.6%, and three segments in 23.8%. Adherence to guideline-recommended biopsy strategies improved over time, with reduced single-segment sampling and increased use of ≥ 2 segments. Distal esophageal biopsies provided the highest diagnostic sensitivity, and sampling that included the distal segment achieved sensitivity above 97%, particularly when combined with middle esophageal biopsies. EREFS reporting increased from 88-90% to over 98% in recent years. DD decreased significantly over time (approximately 0.7 years per calendar year), accompanied by a shift from mixed/stricturing to inflammatory phenotypes. CONCLUSION:Increased alignment with international guidelines, reflected by standardized endoscopic reporting and multi-segment biopsy protocols, was associated with improved diagnostic sensitivity, reduced DD, and fewer fibrostricturing presentations.
BACKGROUND:While portal hypertension (PH) typically resolves after liver transplantation (LT), persistence of PH may affect post-transplant outcomes. We assessed the evolution of PH after LT and its impact on adverse outcomes. METHODS:We recorded clinical, laboratory, and imaging parameters of LT recipients between 2016 and 2022 in Vienna and Zagreb. Persistent features of CSPH were defined as the presence of portosystemic collaterals, platelet count (PLT) ≤ 110 G/L, and/or splenomegaly (≥ 13 cm). PH-related clinical events were defined as variceal bleeding, ascites requiring intervention, hepatic hydrothorax, portal vein thrombosis, or liver-related death within 12 months post-LT. Post-LT outcomes were analyzed using landmark Cox regression for 3 months post-LT. RESULTS:Of 645 LT recipients (76% male, median age 59 years) listed with a median MELD of 15 points and PLT of 99 G/L, features of CSPH were present in 537 (83.3%) at baseline. At year 1 after LT, MELD improved to 9 (IQR 7-12), PLT increased to 160 G/L (IQR 120-207), and features of CSPH persisted in 251/453 classifiable patients (55.4%). PH events occurred in 75 (11.6%) and 84 (13%) deaths. In a landmark analysis from 3 months post-LT (n = 521, 29 deaths), persistent thrombocytopenia (< 110 G/L) at M3 independently predicted mortality (aHR 2.31, 95% CI 1.01-5.30, p = 0.048) after adjustment for MELD, age, CRP, and pre-LT TIPS. CONCLUSIONS:While PH improves after LT, features of CSPH persisted in 55% of classifiable patients and PH-related clinical events occurred in 11.6% within the first year after LT. Persistent thrombocytopenia (< 110 G/L) at 3 months post-LT independently predicted post-LT mortality (aHR 2.31, 95% CI 1.01-5.30, p = 0.048).
Multiplex polymerase chain reaction (PCR) panels are increasingly used for the evaluation of acute diarrhea, providing rapid and sensitive detection of a broad range of enteric pathogens. However, their widespread adoption has created important interpretive challenges for clinicians. Positive results may reflect colonization, prolonged shedding, or organisms of uncertain pathogenicity rather than active infection, and current panels do not provide antimicrobial susceptibility or quantitative information. Incomplete pathogen coverage and false-positive detections may further complicate result interpretation, particularly in patients with mild or self-limited disease. Inappropriate test ordering or overinterpretation of results may lead to unnecessary antimicrobial therapy, delayed evaluation of non-infectious causes of diarrhea, and increased healthcare utilization. This review summarizes the key limitations of multiplex GI PCR panels and provides a practical framework for integrating molecular results with clinical presentation, disease severity, and patient risk factors to support informed management decisions in everyday clinical practice.
BACKGROUND:Functional dyspepsia (FD) is characterised by postprandial fullness, early satiation, epigastric pain, or burning without structural abnormalities on upper endoscopy. Proton pump inhibitors (PPIs) are the preferred first-line therapy. Given that the diagnosis of FD is largely based on symptom assessment, it remains unclear whether acid-suppression meaningfully influences symptom presentation. OBJECTIVE:This exploratory study aimed to determine the prevalence of acid-suppressive therapy (PPIs or H2 receptor antagonists (H2RAs)) among FD patients and to compare symptom patterns between patients with and without these treatments. METHODS:In this single-centre, cross-sectional observational study, ambulatory patients referred for diagnostic upper endoscopy completed the Waiting Room Questionnaire (WRQ). Endoscopic findings were recorded, and FD was defined using Rome IV. Acid-suppression was defined as self-reported use of PPIs or H2RAs. Symptom frequency was compared between patients on and off therapy. RESULTS:1158 patients completed the WRQ; 27% fulfiled the criteria for FD. Among FD patients, 60% reported acid-suppressive therapy, similar to patients with endoscopic findings. FD patients receiving acid-suppression reported higher frequencies of early satiation (OR = 1.68, 95% CI 1.08-2.60), nausea (OR = 1.93, 95% CI 1.23-3.01), and epigastric pain (OR = 1.74, 95% CI 1.12-2.69). In subgroup analyses, therapy was associated with more frequent epigastric burning in postprandial distress syndrome (OR = 3.81, 95% CI 1.50-9.67) and higher frequencies of postprandial fullness (OR = 2.90, 95% CI 1.24-6.80) and early satiation (OR = 2.34, 95% CI 1.13-4.85) in the overlap subgroup. CONCLUSIONS:FD is prevalent in open-access endoscopy, and acid-suppressive therapy is frequently used in this population. FD patients receiving acid-suppression reported slightly higher frequencies of several symptoms, highlighting the need to further explore these associations.
BACKGROUND:Noncoeliac gluten sensitivity (NCGS) remains a controversial clinical entity at the intersection between disorders of gut-brain interaction (DGBI) and disordered eating. We aimed to determine the prevalence of self-reported NCGS and to characterise its association with DGBI and avoidant/restrictive food intake disorder (ARFID) symptoms in an adult general population. METHODS:We conducted a population-based internet survey with pre-defined demographic quotas across the United States of America and United Kingdom in 2023. Participants completed the Rome IV diagnostic questionnaire, the Nine-Item ARFID screen, and validated instruments for psychological distress, somatisation and quality of life. RESULTS:A total of 4002 participants (50% female; median age 46 years) were included in the analyses. The prevalence of NCGS was 14.2% (95% CI, 13.1-15.3). Participants with self-reported NCGS reported more nongluten food intolerances than those without self-reported NCGS (median 3 vs. 0, p < 0.001). Among individuals with NCGS, 69.4% (95% CI, 65.4-73.1) had concomitant DGBI and/or ARFID symptoms, with nearly one-quarter (24.0%; 95% CI, 20.6-27.8) meeting the criteria for all three conditions. Those with comorbid self-reported NCGS, DGBI and ARFID symptoms had the highest levels of psychological distress, somatic symptom reporting, increased healthcare utilisation and reduced quality of life (all p < 0.001). CONCLUSION:NCGS is reported by approximately one in seven adults in the United States of America and United Kingdom. Individuals with self-reported NCGS frequently meet diagnostic criteria for DGBI and/or ARFID symptoms, and those who experience all three entities represent a distinct high-severity phenotype. Our findings suggest that self-reported NCGS may represent a broader syndrome of food-related symptom attribution rather than gluten-specific pathology.
BACKGROUND:Fatty pancreas is a metabolically active ectopic fat depot, but its cardiometabolic implications have been assessed using heterogeneous thresholds. We investigated the association of fatty pancreas, quantified using MRI-derived proton density fat fraction (PDFF) and categorised according to 2026 international consensus thresholds, with prevalent and incident type 2 diabetes (T2D), chronic kidney disease (CKD) and major adverse cardiovascular events (MACE). METHODS:We analysed 19,255 European-ancestry participants from the UK Biobank imaging sub-study. Pancreatic PDFF was categorised as normal (< 6%), mild (6 to < 16%) and moderate-to-severe fatty pancreas (≥ 16%). Outcomes were ascertained through national health records. Associations were estimated using multivariable logistic regression and Cox models, adjusted for age, sex, BMI-defined obesity, elevated MRI-derived visceral adipose tissue and outcome-specific covariates. RESULTS:Moderate-to-severe fatty pancreas was associated with prevalent and incident T2D (OR 3.25, 95% CI 2.49-4.27; p < 0.001; HR 2.72, 1.66-4.46; p < 0.001), incident CKD (HR 1.82, 1.29-2.57; p < 0.001), and prevalent and incident MACE (OR 1.26, 1.04-1.56; p = 0.022; HR 1.30, 1.02-1.66; p = 0.034). Mild fatty pancreas was associated with incident T2D (HR 2.19, 1.40-3.42; p < 0.001) and incident MACE (HR 1.29, 1.06-1.59; p = 0.013). Each 5% increase in pancreatic PDFF was associated with higher odds and hazard of T2D (OR 1.16, 1.12-1.21; HR 1.17, 1.09-1.25; both p < 0.001). CONCLUSIONS:Fatty pancreas was independently associated with prevalent and incident T2D, incident CKD and, more modestly, with MACE. These findings position fatty pancreas within the cardiovascular-kidney-metabolic continuum and support the clinical relevance of consensus-based PDFF thresholds for cardiometabolic risk assessment in European-ancestry populations.
BACKGROUND:Histological assessment of mucosal biopsies in patients with ulcerative colitis (UC) can determine the activity and extent of disease and assess response to treatment. However, its widespread adoption is limited by the time required for the advanced GI specialty training to handle and review histopathology digital images, inter- and intra-observer variability, and cost associated with the interpretation of data. Artificial intelligence, and specifically machine learning‒driven medical image processing, have emerged to help standardise and automate histopathologic assessments. METHODS:In this global study conducted with participation of 38 sites in 19 countries (global roll-out phase), we collected histopathologic slides prepared from biopsy samples from patients with UC to train an AI model to recognise various cell types and assign a disease activity score based on the Nancy histological index (NHI). Results were compared with findings from a previous iteration of the machine learning model (pilot roll-out phase). RESULTS:In total, 850 tiles were analysed and used for training, validation, and testing. Model quality, assessed using the Nancy metric, improved from 61.50% in the pilot roll-out phase to 74.82% in the current global roll-out phase. Cell detection quality (F1-score metric) also increased from 27.50% (pilot roll-out) to 58.80% (global roll-out). CONCLUSIONS:In this global roll-out, the quality of the AI model was significantly improved for both NHI scores and cell detection. Further development and implementation of the model at the participating international sites continues and may lead to a valuable and scalable tool for the analysis of disease activity in UC.
ABSTRACT Introduction Acute pancreatitis (AP) is a major cause of gastrointestinal hospitalizations worldwide. Although typically self‐limiting, up to one‐third of cases develop complications associated with increased morbidity and mortality. Despite recent advances that have improved outcomes, clinical heterogeneity necessitates updated, evidence‐based guidance. In addition, there remains a need to improve the implementation of evidence‐based recommendations across Ibero‐Latin American countries by bringing together diverse scientific societies and regional experts to enhance applicability and the dissemination of best practices. This guideline offers comprehensive recommendations for both mild and complicated AP diagnosis and management. Methods Questions on AP management were addressed by expert teams comprising one coordinator and four pancreatology specialists from the Iberian Peninsula and Latin America. For each question, a systematic review was conducted using PubMed, Embase, and the Cochrane Library, focusing on randomized controlled trials and systematic reviews published between January 1979 and March 2024 in English, Spanish, or Portuguese. In the absence of high‐quality evidence, the search was expanded to include observational studies. Recommendations were formulated using the GRADE system and submitted to an expert panel for consensus; unresolved questions were revised and resubmitted until consensus was reached. Results Twenty evidence‐based recommendations were developed, addressing key aspects of AP management, including definitions, diagnostic criteria, etiological assessment, initial management, management of local complications, splanchnic vein thrombosis, abdominal compartment syndrome, indications for intensive care admission, antibiotic use, early endoscopic retrograde cholangiopancreatography, timing of cholecystectomy, strategies for detecting choledocholithiasis, and the management of pancreatic function insufficiency. Each recommendation included a statement, the level of evidence, the strength of the recommendation, and a summary of the supporting evidence. Conclusion The iLATAM guidelines are the first Ibero‐Latin American clinical practice guidelines for AP. They provide evidence‐based recommendations integrating medical, endoscopic, and surgical approaches, with the aim of promoting consistent, high‐quality care across diverse healthcare settings. Trail Registration In alignment with international standards for transparency and methodological rigor, the methodological protocol for this guideline was registered in PROSPERO (International Prospective Register of Systematic Reviews) on July 23, 2022 (Registration ID: CRD42022345788).
