Background and Aims: Colonoscopy quality assessment is essential for adequate bowel preparation and complete examination, yet even validated tools such as the Boston Bowel Preparation Scale (BBPS) remain partly subjective. We assessed interobserver variability in expert evaluation using a standardized multicenter video dataset. Methods: This retrospective multicenter study included 64 anonymized complete colonoscopy videos from two academic centers. Eight experienced gastroenterologists independently evaluated recordings in randomly assigned pairs. Videos were assessed by five reviewer-pair combinations; individual reviewers evaluated between 10 and 33 examinations, and each pair assessed between 10 and 23 videos. Assessments included segmental and total BBPS scores, bowel preparation adequacy, and recognition of key anatomical landmarks: ileocecal valve, appendiceal orifice, hepatic and splenic flexures, and anal verge. Interobserver agreement was assessed using linear weighted Cohen's kappa for segmental BBPS scores, intraclass correlation coefficient (ICC) for total BBPS score, and Cohen's kappa with overall percent agreement for bowel preparation adequacy and anatomical landmark recognition. Because reviewer pairs varied across examinations, agreement measures were interpreted as pooled pairwise agreement across independent expert assessments. The Wilcoxon signed-rank test was retained as a complementary analysis for paired BBPS score differences. Results: Significant inter-reviewer variability was observed in BBPS scoring. Differences were found for the right colon, transverse colon, left colon, and total BBPS score: 2.42 vs 1.91, p<0.01; 2.47 vs 2.11, p<0.01; 2.44 vs 2.22, p<0.05; and 7.33 vs 6.23, p<0.01, respectively. Overall, bowel preparation adequacy classification did not differ significantly, although discordant judgments occurred in 34% of examinations. Anatomical landmark recognition also varied, particularly for the appendiceal orifice and colonic flexures. Conclusions: Expert-based assessment may show clinically relevant variability despite standardized review conditions, supporting the need for more objective and reproducible approaches to colonoscopy quality control.

BACKGROUND AND AIMS:Inflammatory bowel diseases (IBD), including Crohn's disease (CD), ulcerative colitis (UC), and IBD-unclassified (IBD-U), are increasingly recognized across Eastern Europe, including Romania, where historical data indicated low incidence. Contemporary real-time epidemiological data for our country are scarce. This study evaluated the short-term frequency and epidemiological characteristics of IBD patients presenting to major Romanian gastroenterology centers. METHODS:We conducted a prospective, cross-sectional observational study over a 14-day period in November 2024 across 18 university-affiliated tertiary gastroenterology clinical sites in Romania. All consecutive adult patients with confirmed IBD were enrolled using a centralized online platform. Demographics, disease type and phenotype, severity, and treatment were recorded and analyzed descriptively. RESULTS:A total of 1,045 patients were registered: 52.4% CD, 46.9% UC, and 0.7% IBD-U. Geographical distribution revealed a statistically significant variation, with Crohn's disease being more frequent in Southern Romania, while UC predominated in the Eastern and Central-western regions (p=0.0009). Most patients resided in urban areas, and the majority were in clinical remission at presentation. Phenotypic analysis revealed ileocolonic CD (L3) and left-sided/pancolitis UC (E2/E3) as most frequent. Severe disease history was more common in CD, and prior surgery was significantly higher in CD than UC. Smoking and appendectomy were more frequently associated with CD as previously reported. Therapeutic patterns reflected disease type: anti-TNF use predominated in CD, while other biologics and small molecules were more common in UC. Regional differences in therapy were observed, with southern centers showing higher use of novel therapies, likely reflecting a more mature IBD population, with a higher CD prevalence. Notably, the number of IBD diagnoses increased over time, correlating with Romania's GDP growth (R² = 0.89, p < 0.001), suggesting that socioeconomic factors may influence disease recognition and diagnosis. CONCLUSIONS:This study offers the most recent snapshot of IBD epidemiology in Romania, highlighting a transition toward medium-incidence patterns and growing clinical complexity. These findings provide evidence for the need to establish nationwide population-based surveillance systems and healthcare planning initiatives aimed at mitigating the rising burden of IBD.

Background/Objectives: Acute-on-chronic pancreatitis (ACP) is a fibro-inflammatory syndrome that stands at the border between acute pancreatitis (AP) and chronic pancreatitis (CP). It can be broadly defined as an acute exacerbation of CP. Large language models (LLMs) are artificial intelligence (AI) machine learning tools that can be employed in clinical decision systems (CDSs). Methods: This is an exploratory benchmark study. Six LLM chatbots were evaluated on a Likert scale by a panel of 13 experts in pancreatology based on the similarity of responses to a position statement (PS) in ACP. Results: ClaudeAI had the best average Likert score, while Alice had the lowest. There was a positive correlation between the length of the response and expert-perceived similarity. There was no correlation between seniority and Likert score. Conclusions: In this exploratory benchmark, some LLMs generated answers that were often judged as similar to the position statement, suggesting that they might be helpful as educational support tools and may assist in the refinement of research questions or in the identification of research gaps in this particular pathology.

Background: Sarcopenia is a frequent and clinically relevant condition in patients with pancreatic neoplasm, contributing to poor prognosis, reduced therapeutic tolerance, and increased mortality. The identification of reliable circulating biomarkers, alongside imaging-based muscle assessment, may improve early detection and risk stratification. Methods: This randomized prospective study included 61 patients, of whom 36 had pancreatic neoplasm associated with sarcopenia and 25 served as controls. Serum levels of osteonectin (SPARC), C-terminal agrin fragment (CAF), procollagen type III N-terminal peptide (P3NP), myostatin (MSTN), and insulin-like growth factor-1 (IGF-1) were measured using ELISA. Skeletal muscle index (SMI) and psoas muscle index (PMI) were assessed using CT at the L3 level. Results: Patients with pancreatic neoplasm and sarcopenia showed significantly altered biomarker profiles compared to controls. Osteonectin (median 936.4 vs. 539.9, p 0.001), CAF (2135.9 vs. 1165.5, p 0.001), P3NP (8.01 vs. 5.34, p 0.001), myostatin (47.71 vs. 7.85, p 0.001), and IGF-1 (142 vs. 106.7, p 0.001) were all elevated. The highest biomarker levels were consistently observed in the pancreatic neoplasm group compared to other disease groups. Additionally, 100% of patients with pancreatic neoplasm exhibited reduced SMI, confirming the high prevalence of sarcopenia. Biomarker levels were not significantly influenced by tumor location. Conclusions: The combined use of circulating biomarkers and CT-derived muscle indices provides a clinically relevant approach for identifying sarcopenia in pancreatic cancer.

BACKGROUND:Post-bariatric complications increasingly reach emergency centers that did not perform the index operation, but real-world data from non-index receiving centers are scarce. METHODS:Retrospective, descriptive, episode-level study at a regional emergency center performing no bariatric surgery. We included 45 keyword-identified emergency or semi-elective presentations (March 2021-May 2025) of patients operated elsewhere, recording demographics, index procedure, operation-to-presentation interval, workup, management, diagnosis, and short-term outcomes. RESULTS:Of 45 episodes (33 emergency, 12 semi-elective), 73% involved women; median age 44 years, median BMI 36 kg/m²; SG was the index procedure in 84% (sleeve-type anatomy 89%). The interval exceeded 90 days in 56%. The spectrum was led by biliary/pancreatic disease (27%; 9 of 12 semi-elective), foregut leak/fistula (16%), obstruction/hernia (16%) and foregut stenosis/mucosal/reflux-like disease (22%). Invasive management was used in 80%, intensive care in 20%; 11 episodes (24%) met the severe-course composite and 7 (16%) the narrower high-acuity definition, all in the emergency stream. One in-hospital death occurred (2.2%). CONCLUSIONS:The cohort showed two streams: a predominantly biliary, semi-elective stream, invasive but without severe clinical course, and an acute stream carrying all observed severity. Reflux-like symptoms after bariatric surgery may mask structural disease. These proportions describe referral case mix, not incidence.

Background: Sarcopenia is a common complication and an important negative prognostic factor in patients with liver cirrhosis, being associated with reduced muscle mass and function, as well as increased mortality. Although computed tomography (CT) is considered the gold standard for assessing muscle mass, there is growing interest in identifying serum biomarkers that may facilitate the early diagnosis and monitoring of disease progression. The aim of this study was to evaluate the diagnostic value of osteonectin, the C-terminal agrin fragment (CAF), the N-terminal propeptide of type III procollagen (P3NP), and myostatin in patients with liver cirrhosis and sarcopenia, in correlation with CT-derived imaging parameters. Materials and Methods: A prospective observational caseâcontrol study was conducted, including 60 participants: 30 patients with liver cirrhosis (with or without hepatocellular carcinoma) and sarcopenia, and 30 healthy control subjects. Sarcopenia was diagnosed according to the European Working Group on Sarcopenia in Older People 2 (EWGSOP2) criteria, using the skeletal muscle index (SMI) and psoas muscle index (PMI) measured by computed tomography. Serum concentrations of osteonectin, CAF, P3NP, and myostatin were determined using enzyme-linked immunosorbent assay (ELISA). Statistical analyses included parametric and non-parametric tests, as well as Pearson correlation analysis. Results: Patients with liver cirrhosis and sarcopenia exhibited significantly higher serum levels of osteonectin, CAF, P3NP, and myostatin compared with healthy controls (p 0.001 for all comparisons). The skeletal muscle index was significantly lower in cirrhotic patients, confirming the presence of muscle wasting. Correlation analysis demonstrated positive associations between osteonectin and CAF (r = 0.441, p 0.001), osteonectin and P3NP (r = 0.313, p = 0.016), osteonectin and myostatin (r = 0.444, p 0.001), as well as a strong correlation between CAF and myostatin (r = 0.882, p 0.001). No significant associations were observed between biomarker levels and viral etiology or ChildâPugh class. Conclusions: Simultaneous assessment of osteonectin, CAF, P3NP, and myostatin, combined with computed tomography-based imaging evaluation, may improve the diagnosis of sarcopenia associated with liver cirrhosis and facilitate the early identification of patients at increased risk of muscle deterioration. Larger multicenter prospective studies are warranted to validate the clinical utility of these biomarkers in routine medical practice.

Introduction Colorectal cancer is a major global health concern, with colonoscopy as the gold standard for detection and prevention. Accurate localization of findings remains challenging, limiting reporting objectivity and completeness, which can be supported by artificial intelligence (AI). We present an AI system that identifies the appendiceal orifice, ileocecal valve, and flexures, enabling automated colon segment localization. Methods The AI was trained on 7264 manually annotated images from 991 patients and internally evaluated on 1238 images from 215 patients. Performance was assessed using accuracy, sensitivity, specificity, and F1-score. External validation was conducted on 78 public videos. The impact on standardized reporting was evaluated on 14 videos recorded in a different external clinic that did not contribute training data. These were independently evaluated by two expert endoscopists who reached a consensus that was used as the gold standard for flexure detection. Results On the internal image test set, the AI achieved 94.5% accuracy, 76.7% sensitivity, 97.0% specificity, and 0.79 F1-score. In external validation on videos from a public dataset, the AI identified 91.7% of cecum segments and 66% of flexures, with 81.4% detected within 30 s of annotation. AI integration improved flexure identification in the external video dataset from the second clinic, increasing detected flexures by 53.8% and videos with both flexures identified by 133.3%. Conclusions The AI reliably detects key anatomical landmarks, supporting colon segment localization. Its integration into reporting pipelines could enhance lesion localization, improve report completeness, and reduce documentation workload.

Background: Hepatic encephalopathy (HE) is a severe neuropsychiatric complication of advanced liver disease, driven primarily by ammonia accumulation due to impaired hepatic detoxification and portosystemic shunting. Lactulose is a cornerstone therapy, while rifaximin serves as an effective adjunct for reducing recurrence and hospitalizations. Methods: We conducted a retrospective cohort study at Constanța Emergency County Hospital from January 2022 to March 2025, including 120 adult patients diagnosed with HE. Inclusion criteria were confirmed diagnosis of cirrhosis with clinical and/or biochemical evidence of HE. Patients with other primary neurological disorders or incomplete medical records were excluded. Data on demographics, comorbidities, laboratory results, and medications were collected. Statistical analyses were performed employing descriptive statistics, Friedman’s two-way ANOVA by ranks for medication use, and Cox proportional hazards regression to assess survival associations. Results: The mean age was 61.19 years, with high prevalence of anemia (mean hemoglobin: 9.35 g/dL) and thrombocytopenia (mean: 121.86 × 103/µL). Inflammatory markers were elevated (mean CRP: 36.95 mg/L; ESR: 55.83 mm/h), and INR averaged 1.86. Lactulose was administered to 63.3% of patients, rifaximin to 52.5%, with diuretics, pantoprazole, and albumin being frequently used. Friedman’s analysis ranked lactulose highest in usage frequency. Cox regression indicated no significant short-term survival difference associated with toxic encephalopathy or rifaximin use. Conclusion: In this cohort, lactulose remained the primary treatment for HE, often complemented by supportive pharmacotherapy. While rifaximin use was limited, the overall medication patterns reflected standard practice priorities in HE management.

Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most prevalent chronic liver disease globally, and current estimates indicate an increase in incidence and prevalence in the general population. The design of the prospective study was to evaluate the response of patients with MASLD to an original formula consisting of silymarin, vitamin E, and essential phospholipids. In total, 200 patients were initially enrolled in the study and a total of 190 who participated in all four visits were included in our analysis. During the visits, liver function tests, lipid profiles, blood glucose level, fibrosis, and steatosis values and grades were assessed. From baseline, visit 0, to month 6th, visit III, a statistically significant difference (p-value < 0.0001) was observed in the reduction in ALT, AST, GGT, ALP, TG, total cholesterol, and blood glucose levels. There was a significant decrease in the fibrosis value from the first visit to the last visit (p = 0.002). Even though administered separately, silymarin, essential phospholipids, and vitamin E have established their efficacy in MASLD, this study demonstrates that their combination produces an indubitable effect on liver steatosis, even in a short cure of 6 months, and it can be proposed due to it having no adverse effects on patients with MASLD.

Background: Chronic ethanol consumption is a major global health concern traditionally associated with liver disease. Ethanol disrupts gut microbial communities, compromises intestinal barrier function, and contributes to hepatic, metabolic, and neurocognitive disorders. Methods: We conducted a systematic PubMed search and meta-analysis of 11 human and 19 animal studies evaluating ethanol-induced gut microbiota alterations. Studies were assessed for microbial diversity, taxonomic shifts, barrier integrity, and systemic effects. Effect sizes were calculated where possible, and interventional outcomes were examined. Results: Across species, ethanol exposure was consistently associated with reduced microbial diversity and depletion of beneficial commensals such as Faecalibacterium, Lactobacillus, Akkermansia, and Bifidobacterium, alongside an expansion of proinflammatory taxa (Proteobacteria, Enterococcus, Veillonella). Our analysis uniquely highlights discrepancies between human and animal studies, including opposite trends in specific genera (e.g., Akkermansia and Bifidobacterium) and the impact of confounders such as antibiotic exposure in human cohorts. We also demonstrate that microbiota-targeted interventions can partially restore diversity and improve clinical or behavioral outcomes. Conclusions: This meta-analysis highlights reproducible patterns of ethanol-induced gut dysbiosis across both human and animal studies.

Background: Hydatid disease, caused by the larval form of Echinococcus granulosus, is a rare but potentially life-threatening condition during pregnancy, with an estimated incidence of 1 in 20,000 to 30,000 gestations. Physiological immunosuppression and increased placental steroid levels during pregnancy may promote cyst growth, elevating the risk of rupture, which can result in anaphylactic shock, sepsis, or widespread peritoneal dissemination. Diagnostic imaging, particularly ultrasonography, plays a central role in detection, while treatment decisions are complicated by the lack of standardized guidelines and the need to balance maternal–fetal safety. Methods: This case report describes a 29-year-old pregnant woman at 22 weeks’ gestation who was incidentally diagnosed with two large hepatic hydatid cysts during a routine ultrasound. Results: Given the high rupture risk, she underwent successful laparoscopic surgery in the second trimester, followed by careful monitoring and elective cesarean delivery at term. A third retroperitoneal cyst, initially managed conservatively, was excised postpartum. Conclusions: This case highlights the critical importance of individualized, multidisciplinary management in achieving favorable maternal and neonatal outcomes in complex presentations of hydatid disease during pregnancy.

Pulmonary complications are an important yet underappreciated aspect of inflammatory bowel disease (IBD), which includes Crohn’s disease (CD) and ulcerative colitis (UC). These conditions often manifest with extraintestinal symptoms that can significantly influence the clinical trajectory of the disease. Pulmonary involvement in IBD can range from mild symptoms, such as a persistent cough, to severe conditions, including interstitial lung disease or pulmonary embolism. This systematic review aims to assess the prevalence, clinical presentations, and implications of pulmonary involvement in IBD patients. A comprehensive literature search was conducted using PubMed database up to the 1st of May 2024. Inclusion criteria focused on studies involving adult IBD patients with documented pulmonary symptoms, evaluated through clinical, radiological, and histopathological approaches. Of the 463 studies identified, 27 met the inclusion criteria, consisting of 36,264 patients. Pulmonary manifestations were classified into airway diseases and parenchymal involvement. Airway diseases, including bronchiectasis and chronic bronchitis, were the most common, followed by parenchymal conditions such as organizing pneumonia and interstitial lung disease (ILD). Smoking was identified as a significant risk factor for pulmonary involvement. Pulmonary involvement in IBD is diverse and often underdiagnosed. Early recognition and management are crucial to improving patient outcomes.

Background: Chronic constipation is a well-recognized complication which is caused by hard and/or infrequent defecation. According to estimates, constipation presents as a chronic illness affecting 16% of adults globally, who deal with insufficient bowel movements that cause discomfort, bloating, or a sensation of incomplete bowel. Objectives: This review looks at the many local and systemic factors that contribute to the pathogenesis of the causative, including dietary habits, genetic factors, colon function and absorption, social and economic factors, lifestyle, and biological and drug factors. Results: Appropriate diagnostic and management modalities are the cornerstone in the management of patients with chronic constipation. However, there are still controversies regarding the timing of these diagnostic and management approaches. This condition is common and reduces the quality of life of patients and represents a burden on any healthcare system. In clinical practice, it remains problematic, as physicians are most of the time indecisive on which therapy to administer and at what time. Conclusions: Constipation management is a new topic that was introduced over a decade ago and the purpose of this study is to shed some light onto the practice, problems and modern day techniques that can be used to treat constipation in patients, primarily through behavioural, conservative, medical, and surgical means. Additionally, this particular management is to be used in conjunction with an algorithm designed to enhance and support clinical practice.

Recent research highlights a potential link between metabolic dysfunction-associated steatotic liver disease (MASLD) and intestinal barrier dysfunction. Increased intestinal permeability (IP) may facilitate the translocation of bacteria, endotoxins (e.g., lipopolysaccharides [LPS]), and pathogen-associated molecular patterns into the portal venous system, fostering a pro-inflammatory environment and contributing to liver inflammation. This study aimed to identify correlations between intestinal barrier biomarkers (occludin, LPS, and intestinal-type fatty-acid-binding proteins [I-FABP]) and MASLD. A single-center prospective cross-sectional study was conducted, including 72 MASLD patients and 68 healthy controls. Fibroscan-controlled attenuation parameter (CAP) was performed in all subjects. Blood samples were analyzed for biochemical parameters, and serum levels of occludin, LPS, and I-FABP were measured using the ELISA method with the Human occludin, LPS, and I-FABP ELISA Kit test systems (FineTest, Wuhan, China). LPS and I-FABP levels were significantly higher in MASLD patients compared to controls, with the highest LPS levels observed in the diabetic MASLD subgroup. Occludin levels showed no statistically significant differences between groups. All 3 biomarkers were positively correlated with BMI, with the highest levels in obese subjects. LPS was positively correlated with CRP levels. Using Fibroscan-CAP, we found a positive correlation between LPS and both liver stiffness and CAP score, as well as between I-FABP and liver stiffness. MASLD patients exhibit increased IP, with enterocyte injury present irrespective of diabetes status, though more pronounced in diabetic MASLD. Occludin does not appear to be a reliable biomarker for evaluating intestinal barrier function in MASLD. Obesity is linked to elevated biomarkers, suggesting an association between increased IP and obesity. I-FABP and LPS may serve as noninvasive biomarkers for assessing hepatic fibrosis and steatosis in MASLD patients. Notably, LPS, given its correlation with elevated CRP levels, could be utilized as a marker of disease progression and severity.

BACKGROUND:In recent years, increased intestinal permeability has been considered a hallmark of liver cirrhosis (LC), thereby exposing the liver to many bacteria and microbial components of a leaky gut, such as zonulin which is a recognized biomarker of intestinal permeability. The topic is underresearched and professional consensus regarding intestinal permeability in cirrhosis is still lacking. Our systematic review and meta-analysis aimed to investigate the intestinal permeability assessed by serum zonulin levels in patients with LC. METHODS:The systematic search covered 3 databases with the following search key: "zonulin" AND "LC" OR "cirrhosis." Our investigated population (P) consisted of patients diagnosed with LC. Eligible studies compared the levels of serum zonulin in patients with LC (I) to the control group (C). Our primary outcome (O) was the difference in serum zonulin in patients with LC compared with controls (PROSPERO CRD42024580574). RESULTS:In total, 4 studies fulfilled the eligibility criteria for the qualitative and quantitative analysis. The mean effect size estimate was 0.590 (95% confidence interval: 0.325-0.855) and statistically significant (t = 4.378, P < .001). For heterogeneity, Q-statistics and I2 values were examined. The Q-statistics (Q = 123.4974, df = 3, P < .0001) was found to be statistically significant. In addition, the I2 value was found to be 97.57% (95% confidence interval: 95.83-98.59). As a result, there was a statistically significant heterogeneity between studies. CONCLUSION:In this systematic review and meta-analysis, we summarized the current evidence on the importance of zonulin. Currently, there is no clear evidence regarding the axis between the gut and liver, particularly cirrhosis, and zonulin is known as a surrogate biomarker for a leaky gut. An important aspect to consider is the fact that zonulin is primarily produced in the liver; in cases of LC, its synthesis is impaired, which is why zonulin cannot be considered a marker of intestinal permeability in this pathology. Further randomized controlled trials assessing this impaired intestinal permeability and gut-liver axis in patients with liver diseases will be necessary.

Background: Recent studies have shown that gut microbiota have important roles in different human diseases. There has been an ever-increasing application of high-throughput technologies for the characterization of microbial ecosystems. This led to an explosion of various molecular profiling data, and the analysis of such data has shown that machine-learning algorithms have been useful in identifying key molecular signatures. Results: In this review, we first analyze how dysbiosis of the intestinal microbiota relates to human disease and how possible modulation of the gut microbial ecosystem may be used for disease intervention. Further, we introduce categories and the workflows of different machine-learning approaches and how they perform integrative analysis of multi-omics data. Last, we review advances of machine learning in gut microbiome applications and discuss challenges it faces. Conclusions: We conclude that machine learning is indeed well suited for analyzing gut microbiome and that these approaches are beneficial for developing gut microbe-targeted therapies, helping in achieving personalized and precision medicine.