Anal human papillomavirus (HPV) infection can cause benign and precancerous intra- and perianal lesions. Multiple treatments, including liquid nitrogen cryotherapy, are available with varying efficacy, safety and logistic issues. Little consensus exists considering best clinical practice. This study aims to assess efficacy, safety, and practical applicability of a handheld, noncontact cryotherapy device using nitrous oxide to treat nonmalignant HPV-related intra- and perianal lesions. A single-center exploratory, open-label proof of concept case series was performed followed by a prospective single-arm interventional study with standardized treatment protocol, conducted at the proctology clinic of the Ghent University Hospital (Belgium). Consecutive patients presenting with benign, intra-, and/or perianal HPV-related lesions were offered noncontact cryotherapy treatment. Primary endpoint was clinical remission, within 4 months of treatment. Secondary endpoints included 1 year recurrence rate and treatment-emergent adverse events. Practical applicability of the device was evaluated and technical properties were adjusted to maximize applicability in everyday ambulatory proctology practice. In total, 73 patients were treated. Clinical remission within 4 months was seen in 47/63 (74.6

Background and aims:Obstructed defecation syndrome (ODS) is a multifactorial condition that significantly impairs quality of life and presents diagnostic and therapeutic challenges due to the interaction of functional and anatomical factors. This initiative aimed to develop a Belgian consensus and a diagnostic-therapeutic algorithm to support effective clinical management of ODS. Methods:A Belgian steering group of gastroenterologists and colorectal surgeons (n=6) conducted a Delphi consensus process. Based on a structured literature review, 82 statements were drafted and discussed during three online voting rounds. Consensus was defined as ≥80% agreement, and evidence strength was graded using the GRADE system. Results:Thirty-one experts participated, including gastroenterologists, colorectal surgeons, gynecologists, and physiotherapists. Sixty-two final statements were formulated, of which 46 were endorsed. ODS was defined as a disorder of anorectal evacuation, with functional and structural components often coexisting. Symptoms overlap with functional constipation, IBS-C, and fecal incontinence, and quality of life is substantially impaired. Diagnosis requires multimodal evaluation, including digital rectal examination and anorectal testing. First-line treatment consists of conservative measures such as lifestyle optimization, laxatives, and pelvic floor re-education. Surgery is reserved for selected patients with refractory symptoms and significant anatomical abnormalities. Tailored surgical approaches are supported for rectocele, rectal prolapse, and pelvic organ prolapse, whereas sacral nerve stimulation is not routinely recommended. Conclusion:These consensus statements provide practical guidance for the diagnosis and management of ODS. Conservative therapy remains the cornerstone, with surgery reserved for selected cases. Areas lacking consensus warrant further research.

Perianal Crohn’s disease (pCD) is a challenging form of Crohn’s disease, which includes both fistulising and non-fistulising features, such as anorectal stricture, skin tags and erosive disease (1). Whilst non-fistulising pCD (nfpCD) can result in a significant disease burden for patients, these features are under-recognised in clinical practice, current guidelines and clinical research relating to pCD (2,3). Informed by a review of existing classification systems, this study aimed to develop a novel classification system to guide identification and management of non-fistulising pCD. Following a systematic review to identify existing classification systems, a modified nominal group technique expert consensus process was used to develop a novel classification system for non-fistulising pCD. This process involved several phases including ideas generation, clarification of ideas, several rounds of voting and patient and public involvement (PPI). Twenty-two existing classification systems for non-fistulising pCD were identified, the majority (18/22, 88%) of which focused on categorising non-fistulising pCD. Participating panellists included multidisciplinary experts from the TOpClass consortium, with representation from 10 countries. The initial round of voting established a need for a novel classification system (n = 18 89% [A+], 11% [A]), and passed a number of statements relating to the content of the classification. The final classification structure was passed with 100% consensus (n = 27, 93%,[A+], 7% [A]) (Figure 1). The final statements to accompany the classification were passed with a mean 98% consensus (n = 28, 80% [A+], 18% [A]) (Table 1). The novel structure classifies nfpCD according to the presence of stricturing disease, erosive disease and skin tags with severity ranging from minimal symptoms (Class 1) to severe symptoms requiring defunctioning ostomy (Class 2c), proctectomy (Class 3) or perineal symptoms after proctectomy (Class 4). The structure complements the existing TOpClass classification for fistulising pCD, to enable classification of patients with both fistulising and non-fistulising features of pCD. The classification system incorporates patient goals and symptom burden, and introduces a number of novel concepts, such as velocity and destruction to provide a clinically useful framework. This expert consensus has developed a dynamic, comprehensive and patient-focused system for optimising the classification of patients with non-fistulising pCD for clinical and research use. Further validation in prospective cohorts is planned to ensure clinical applicability. References: 1. Singh B, McC Mortensen NJ, Jewell DP, George B. Perianal Crohn’s disease. British Journal of Surgery. 2004 June 17;91(7):801–14. 2. Bouguen G, Siproudhis L, Bretagne JF, Bigard MA, Peyrin-Biroulet L. Nonfistulizing perianal Crohn’s disease: Clinical features, epidemiology, and treatment. Inflamm Bowel Dis. 2010 Aug 1;16(8):1431–42. 3. Adamina M, Minozzi S, Warusavitarne J, Buskens CJ, Chaparro M, Verstockt B, et al. ECCO Guidelines on Therapeutics in Crohn’s Disease: Surgical Treatment. Journal of Crohn’s and Colitis. 2024 Oct 15;18(10):1556–82. Conflict of interest: Mr. Pelly, Theo: No Conflicts Geldof, Jeroen: Personal Fees: Jeroen Geldof has served as an advisory board member for Arena and as a speaker for Janssen and Galapagos. Anand, Easan: Nil Hanna, Luke: None Joshi, Shivani: Speaker Fees from Lilly Shakweh, Eathar: None. Panchal, Radha: None Kotze, Paulo Gustavo: Grant: Pfizer, Takeda Personal Fees: Abbvie, Johnson & Johnson, Ferring, Pfizer, Takeda, Celltrion Other: Abbvie, Janssen, Ferring, Pfizer, Takeda De Parades, Vincent: - Clinical research: Brothier, Sandoz, Takeda - Advisory boards: Abbvie - Courses, training, conferences: AAbbvie, Amgen, Biolitec, FCare Systems, Janssen, Takeda, THD lab, Tillots De Looze, Danny: No conflict of interest Powell, Nick: Grant: Takeda, BMS, Pfizer, Astra-Zeneca Personal Fees: Abbvie, Abivax, Allergan, Astra-Zeneca, Bristol-Myers Squibb, Celgene, Celltrion, Dr Falk Pharma UK Ltd, Ferring, Galapagos, GSK, Janssen, MSD, Roche, Pfizer, Sobi, Takeda, Tillotts Tozer, Philip: Personal Fees: Takeda - speakers fees, member of Inspire, and advisory boards Ferring - speakers fees Falk - speakers fees Tillott’s - speakers fees J & J - speakers fees Abbvie - speakers fees Hart, Ailsa: Grant: Takeda Personal Fees: Abbvie, Amgen, Arena, AZ, Falk, Celltrion, Eli Lilly, Ferring, Genentech/ Roche, GSK, Pfizer, Takeda, Napp, Pharmacosmos, Janssen (J & J), Bristol-Myers Squibb, Gilead, Galapagos, Alfasigma

Background:Chronic diarrhea is one of the more common reasons for referral to a gastro-enterologist. Chronic diarrhea can have a broad range of causes, making it a disease entity with a very extensive differential diagnosis. In a proportion of patients, however, a cause for the chronic diarrhea cannot be found and these patients are said to have chronic idiopathic diarrhea (CID). Methods:A Delphi model was used to establish a diagnostic strategy for patients presenting with chronic diarrhea that maximizes the chance for a positive diagnosis while minimizing the number and invasiveness of the investigations. In addition, the participating experts sought consensus on the different treatment options that can be used in these patients. Results:While a general consensus was reached on the required diagnostic tests for CID, marked differences were observed on the treatment preferences and strategies for these patients among the different experts. The main reason for this is the lack of solid scientific evidence with the different treatment options in this setting (i.e., most data have been generated in patients with IBS-D). Conclusion:the Delphi-like process that was used for this initiative proved to be a useful vehicle to fuel discussions on the management of CID among experts with different backgrounds and to sketch the current clinical practice.

Colorectal cancer (CRC) is the second and third leading cause of cancer death in men and women respectively worldwide. Colonoscopy is the gold standard screening test to detect premalignant lesions with endoscopic polypectomy preventing evolution to CRC. Endoscopic polypectomy is effective with a higher safety profile and is less costly as compared to surgery. Bestpractice polypectomy technique is crucial, as 10% of polyps <2 cm are incompletely resected and may therefore play a significant role in the development of post colonoscopy colorectal cancer (PCCRC). Hot snare polypectomy (HSP) has traditionally been the technique of choice for endoscopic polypectomy but is associated with a small but appreciable risk of adverse events, primarily postpolypectomy bleeding and perforation. Recent high-quality studies have demonstrated the similar efficacy and superior safety profile of cold snare polypectomy (CSP) for polyps less than 10 mm in size. In daily clinical practice, the vast majority of colorectal polyps encountered by gastroenterologists are less than 10 mm, making CSP the technique of choice. Widespread use of CSP over HSP may therefore significantly reduce the number of adverse events associated with endoscopic polypectomy. The indication for CSP may be extended to larger lesions, including large, non-dysplastic sessile serrated lesions and small pedunculated polyps with a thin stalk. In addition, the risk-benefit ratio of CSP is favourable in patients in whom interruption of anticoagulants is a concern in terms of thromboembolic risk. In this review, the focus will be on safety of hot versus cold snare polypectomy as a technique for the resection of diminutive and small polyps.

Abstract Background Perianal fistulising Crohn’s Disease (PFCD) is a challenging phenotype of IBD associated with poor outcomes. Classically, fistulae have been classified anatomically and guidelines have been generalised, with a lack of appreciation of disease heterogenicity. The recent ‘TOpCLASS classification system’ (Geldof et al. (2022) - figure below) addresses this and categorises patients based on clinical features and patient goals. There is a need to provide management guidance for PFCD that aligns with this approach, targeting differing PFCD manifestations seen in real-life. We present a consensus exercise delivering that guidance. Methods Position statements on ‘optimal’ PFCD management within the TOpCLASS classes were made via a consensus meeting in Apr 2023. The expert panel were members of the TOpCLASS Consortium, a group of PFCD specialists and researchers. This included 15 surgeons and 16 gastroenterologists, from IBD centres in Europe, North America, and Australia. Prior to the meeting, to inform provisional statements: 1) a systematic review of the literature was conducted (Oct 2021), 2) multidisciplinary team responses on the management of fictional PFCD cases from 8 leading IBD centres were obtained, and 3) an open discussion on PFCD management with the expert panel was conducted. Consensus was predefined as ≥80% ‘strongly agree’ [A+] or ‘agree with minor reservation’ [A]. Results 53 position statements were agreed by the expert panel. For Class 1 (minimal, asymptomatic) disease the panel agreed, given the lack of symptoms, there is no role for seton insertion (A+ 50%, A 50%), and no role for routine MRI monitoring in the absence of new fistula symptoms (A+ 46%, A 54%). Regarding Class 2 (chronic, symptomatic) disease, the panel agreed on detailed guidance for when fistulae are suitable for a repair attempt and where differing surgical modalities are best utilised in fistula repair. Additionally, statements on seton removal in PFCD were made, alongside statements on optimised medical therapy in Class 2 patients. Specifically, the panel suggest Infliximab first-line (A+ 80%, A 20%), ideally commenced within 30 days of initial drainage +/- seton insertion (A+ 100%). Statements were also produced regarding second-line options, topical therapy, and loss of response to biologics in PFCD. Specific statements were also developed for Class 2b, 2c-i, 2c-ii, and 4 disease, as well as on the psychological burden of PFCD. Conclusion The generated statements come from a highly expert Western group of PFCD specialists. We believe they provide pragmatic advice to gastroenterologists and IBD surgeons managing the full breadth of PFCD encountered in day-to-day practice.

A 77-year-old man presented with anorexia, nausea, vomiting and bloody diarrhoea. The patient had a past medical history of heart transplantation, multiple myeloma and chronic kidney disease (CKD) requiring haemodialysis. Clinical examination revealed a diffusely tender abdomen. His vital signs included a low blood pressure of 80/55 mmHg, tachycardia of 112 bpm, normothermia (36.2°C) and a SpO2 of 97% when breathing room air. Laboratory studies were significant for haemoglobin 13 g/dL (16 g/dL a few days earlier), CRP 179,8 mg/L, leukocyte count 13,75 x10E3/μL, lactate 4,46 mmol/L and known CKD. A multiphasic contrast-enhanced abdominal computed tomography did not show any acute pathology, nor vascular contrast extravasation.

Introduction:Acute and chronic anal fissures are common proctological problems that lead to relatively high morbidity and frequent contacts with health care professionals. Multiple treatment options, both topical and surgical, are available, therefore evidence-based guidance is preferred. Methods:A Delphi consensus process was used to review the literature and create relevant statements on the treatment of anal fissures. These statements were discussed and modulated until sufficient agreement was reached. These guidelines were based on the published literature up to January 2023. Results:Anal fissures occur equally in both sexes, mostly between the second and fourth decades of life. Diagnosis can be made based on cardinal symptoms and clinical examination. In case of insufficient relief with conservative treatment options, pharmacological sphincter relaxation is preferred. After 6-8 weeks of topical treatment, surgical options can be explored. Both lateral internal sphincterotomy as well as fissurectomy are well-established surgical techniques, both with specific benefits and risks. Conclusions:The current guidelines for the management of anal fissures include recommendations for the clinical evaluation of anal fissures, and their conservative, topical and surgical management.

An anal fissure is a painful tear of the sensitive anoderm, distally from the dentate line. It is a prevalent disorder and impairs quality of life dramatically. Typical or primary fissures are associated with constipation and mostly located at the posterior midline. About 1% of fissures are atypical in appearance and are generally secondary in nature. These secondary fissures should arouse attention and require further exploration for underlying conditions, such as Crohn’s disease, malignancy, trauma or venereal infections. The aim of this manuscript is to provide a comprehensive review on the clinical aspects, evaluation and treatment of secondary anal fissures.

Anal cancer is an uncommon malignancy, comprising only 2.5% of all gastrointestinal malignancies and similar to cervical cancer, the human papillomavirus (HPV) is responsible for the majority of anal cancers. Over the last decades there has been an up to 3-fold increased incidence seen in specific populations at risk such as persons living with HIV (PLWH), men who have sex with men (MSM), woman diagnosed with HPV-related gynaecological precancerous lesions or cancer, solid organ transplant recipients (SOTR) and patients with autoimmune diseases. Although international practice is evolving increasingly towards active screening for and treatment of anal cancer precursors in at-risk groups, currently no organised screening program is in effect in Belgium. Currently, differerent screening options as well as treatment modalities are available. Before commencing a nationwide organised screening program, essential decisions on screening strategies need to be made, based on both scientific as well as financial and logistical facts.

Background: Irritable bowel syndrome (IBS) is characterised by recurrent abdominal pain related to defaecation or associated with altered stool frequency or consistency. Despite its prevalence, major uncertainties in the diagnostic and therapeutic management persist in clinical practice. Methods: A Delphi consensus was conducted by 20 experts from Belgium, and consisted of literature review and voting process on 78 statements. Grading of recommendations, assessment, development and evaluation criteria were applied to evaluate the quality of evidence. Consensus was defined as > 80 % agreement. Results: Consensus was reached for 50 statements. The Belgian consensus agreed as to the multifactorial aetiology of IBS. According to the consensus abdominal discomfort also represents a cardinal symptom, while bloating and abdominal distension often coexist. IBS needs subtyping based on stool pattern. The importance of a positive diagnosis, relying on history and clinical examination is underlined, while additional testing should remain limited, except when alarm features are present. Explanation of IBS represents a crucial part of patient management. Lifestyle modification, spasmolytics and water-solube fibres are considered first-line agents. The low FODMAP diet, selected probiotics, cognitive behavioural therapy and specific treatments targeting diarrhoea and constipation are considered appropriate. There is a consensus to restrict faecal microbiota transplantation and gluten- free diet, while other treatments are strongly discouraged. Conclusions: A panel of Belgian gastroenterologists summarised the current evidence on the aetiology, symptoms, diagnosis and treatment of IBS with attention for the specificities of the Belgian healthcare system.

In het kader van de opkomende preventieve geneeskunde geniet screening een bijzondere plaats. Opgezette programma’s worden geconfronteerd met de algemene principes van de diagnostiek en de criteria van Wilson en Jungner om hun maatschappelijke meerwaarde te bewijzen. In dit e-book worden verschillende initiatieven geëvalueerd op het gebied van carcinomen (prostaat, colon en anaal), perinatale depressieve […]

Introduction : Hemorrhoidal disease is a common problem that arises when hemorrhoidal structures become engorged and/or prolapse through the anal canal. Both conservative and invasive treatment options are diverse and guidance to their implementation is lacking. Methods : A Delphi consensus process was used to review current literature and draft relevant statements. These were reconciliated until sufficient agreement was reached. The grade of evidence was determined. These guidelines were based on the published literature up to June 2020. Results : Hemorrhoids are normal structures within the anorectal region. When they become engorged or slide down the anal canal, symptoms can arise. Every treatment for symptomatic hemorrhoids should be tailored to patient profile and expectations. For low-grade hemorrhoids, conservative treatment should consist of fiber supplements and can include a short course of venotropics. Instrumental treatment can be added case by case : infrared coagulation or rubber band ligation when prolapse is more prominent. For prolapsing hemorrhoids, surgery can be indicated for refractory cases. Conventional hemorrhoidectomy is the most efficacious intervention for all grades of hemorrhoids and is the only choice for non-reducible prolapsing hemorrhoids. Conclusions : The current guidelines for the management of hemorrhoidal disease include recommendations for the clinical evaluation of hemorrhoidal disorders, and their conservative, instrumental and surgical management.

Early detection of precursor lesions of anal cancer in HIV-seropositive patients Although anal cancer is rare in the overall population, its incidence is increasing in the last decades. Especially HIV-seropositive patients have an increased risk of developing anal squamous cell carcinoma (SCC), mainly because of the high prevalence of high-grade anal intraepithelial neoplasia (AIN) among these patients. High-grade AIN is a precursor lesion for anal SCC associated with human papillomavirus (HPV) infection. Despite the lack of direct evidence demonstrating that AIN identification reduces the risk of anal cancer, experts think that screening and treatment of high-risk patients will prevent the disease. This article aims to review the current literature about AIN and discusses the screening options, including digital rectal examination, anal cytology and high-resolution anoscopy.