BACKGROUND AND AIMS:The presence of backwash ileitis, post-colectomy pre-pouch ileitis, or pouchitis has been widely described in the presentation of ulcerative colitis [UC]. However, over the years, a few cases of upper gastrointestinal [UGI] inflammation in patients with UC have been reported, most commonly post-colectomy.  The aim of this review was to conduct an analysis of the current literature to identify the prevalence, risk factors and current treatment of UGI UC.  Methods: Case report and review of the literature. An electronic search of five bibliographic databases [Pubmed, Cochrane, DOAJ, Science Direct, and JSTOR], was conducted. A combination of keywords and medical subject headings [MeSH] related to "small intestine" and "inflammation" or "enteritis" and "colectomy" or "post operative complications" or "ileostomy" or "stoma" and "ulcerative colitis" or "inflammatory bowel disease" were used. Referenced papers not fully available in English text were excluded from the study.  The manuscripts were analysed for age, gender, extent of colonic and UGI disease, timing of UGI presentation, surgical history, treatment and follow-up. RESULTS:We present the case of a 59-year-old woman with diffuse upper gastrointestinal (UGI) ulcerative colitis (UC) that was refractory to steroid treatment, occurring nine years after a panproctocolectomy for medical treatment failure Upon initiation of an anti-TNFɑ [adalimumab], she achieved remission. We then systematically reviewed the literature to analyse previous reports of patients presenting with UGI UC to understand the prevalence and identify risk factors for developing this condition. To date, 43 cases have been published describing UGI UC with a male to female ratio 5:4 with a mean age of 37.52 years [IQ range 27 years] The majority [85.7%] of these patients were post-colectomy secondary to pancolitis. The mean time post-colectomy for UGI UC to occur is 14 months [range 0-12 years]. The prognosis of these patients were generally good; however, severe complications including haemorrhage, perforation and death have been reported. The inflammatory distribution affected the duodenum [74%] > ileum [57%] > jejunum [31%] > stomach [4%]. The majority of patients with reported changes in the stomach had a pangastritis pattern, with only one case describing isolated antral inflammation. No standardised treatment strategy is available, however, intravenous and oral corticosteroids, 5-aminosalicylates, thiopurines, calcineurin-inhibitors, and TNFα-inhibitors, have been found to be effective in treating UGI UC. Only one other case report reported the successful use of adalimumab to attain remission in UGI UC. CONCLUSION:This review sheds light on a rare presentation of UC. This highlights the need for further research into the pathogenesis of UC and treatment strategies for patients presenting with UGI UC. Our case further strengthens the use of anti-TNFɑ, particularly adalimumab for UGI UC and highlights the need for further research into the pathogenesis of inflammatory bowel disease.

Background:Duodenal biopsies are standard for diagnosing celiac disease (CD), but a biopsy-free approach has gained attention in the past decade. Evidence suggests that immunoglobulin A anti-tissue transglutaminase (IgA tTg) antibody levels ≥10 times the upper limit of normal (ULN) may reduce the need for histology. This study aimed to assess whether IgA tTg antibody titers ≥10 × ULN correlate with the histological diagnosis in adults. Methods:The retrospective study was conducted at Mater Dei Hospital, Malta, analyzing adult patients who underwent upper gastrointestinal endoscopy with duodenal biopsies between 2012 and 2024. Data on demographics, symptoms, risk factors, serology and histological results were collected. Patients who had positive serology but initial negative biopsies and underwent repeat biopsies were also reviewed. Results:Of 114 patients (78.1% female, mean age 41.0 years), 97.4% tested positive for IgA tTg antibodies and 93.8% for endomysial antibodies (EMA). CD was histologically confirmed in 70.2%, with females more frequently diagnosed than males (75.3% vs. 52%, P=0.025). CD-related symptoms were reported by 79.8%, while 20.2% were asymptomatic. Levels of tTg ≥10 × ULN were found in 41.2% patients, and this cutoff had a sensitivity of 58.8%, specificity of 100%, positive predictive value of 100% and negative predictive value of 50.7% for CD (P<0.001). Conclusion:This study supports a biopsy-free approach for diagnosing CD when IgA tTg levels are ≥10 x ULN, especially with EMA positivity and typical clinical presentation.

The management of Crohn's disease during pregnancy presents significant challenges. Active Crohn's disease can be treated with corticosteroids or biologics. While these treatments are generally considered safe during pregnancy, they are not without potential side effects, leading to patient hesitancy in initiating therapy despite guidance from inflammatory bowel disease specialists. We present the case of a 34-year-old woman who was diagnosed with Crohn's disease 3 weeks before getting pregnant and who opted not to use medication during her pregnancy. For the initial 26-28 weeks, she received conservative treatment. Following a deterioration in her symptoms and an increase in calprotectin levels, she commenced the Crohn's disease exclusion diet (CDED) combined with partial enteral nutrition (PEN). This led to significant symptomatic improvement and a decrease in faecal calprotectin levels. At 40 weeks of gestation, she gave birth to a healthy baby. This case underscores the potential efficacy of CDED and PEN as dietary management strategies for Crohn's disease even during pregnancy, although further research is warranted to compare these approaches with conventional treatments. In addition, it emphasises the critical role of preconception counselling regarding medication safety and effective disease management during pregnancy.

Introduction Gastroenterology training usually coincides with childbearing years and pregnancy and parenthood during training can impact trainees’ work–life–family balance. Aim The aim was to assess the challenges that gastroenterology trainees in Europe encounter during pregnancy and parenthood. Methodology A questionnaire was distributed electronically, targeting doctors who were pregnant or had a pregnant partner during their gastroenterology training in the last 10 years. Results The study included 82 women and 22 nonpregnant partners. Fear of being perceived negatively was prevalent ( n = 59, 72.0%) as well as concern that the pregnancy would negatively impact on training ( n = 54, 65.9%). Participants reported several hazards that were not addressed during pregnancy, namely exposure to non-scavenged anesthetic gases (34.1%) and exposure to blood-borne illnesses (28.0%). Formal training programs’ maternity leave policies were reported by only 34.1% ( n = 28) of women and 45.5% ( n = 10) of men. Satisfaction with the duration of parental leave was 85.1% ( n = 63) for women and 50% ( n = 11) for men. Women reported greater difficulty coping with early parenthood during gastroenterology training than men (women: n = 14, 18.4% vs. men: n = 10, 45.5%; P = 0.014) while worrying that having children would impair their career progress (women: n = 40, 52.6% vs. men: n = 8, 36.4%; P = 0.015). Conclusion This European study has demonstrated perceptions of negative stigma related to childbearing, concerns of unaddressed health hazards, dissatisfaction with parental leave policies and a desire for more discussion on a healthy work–family–life balance.

The understanding of the potential role of the microbiota in the pathogenesis of inflammatory bowel disease (IBD) is ever-evolving. Traditionally, the management of IBD has involved medical therapy and/or surgical intervention. IBD can be characterized by gut microbiome alterations through various pathological processes. Various studies delve into nontraditional methods such as probiotics and fecal microbiota transplant and their potential therapeutic effects. Fecal microbiota transplant involves the delivery of a balanced composition of gut microorganisms into an affected patient via multiple possible routes and methods, while probiotics consist of live microorganisms given via the oral route. At present, neither method is considered first-line treatment, however, fecal microbiota transplant has shown potential success in inducing and maintaining remission in ulcerative colitis. In a study by Kruis and colleagues, Escherichia coli Nissle 1917 was considered to be equivalent to mesalamine in mild ulcerative colitis. Alteration of the microbiome in the management of Crohn’s disease is less well defined. Furthermore, variation in the clinical usefulness of 5-aminosalicylic acid medication has been attributed, in part, to its acetylation and inactivation by gut microbes. In summary, our understanding of the microbiome’s role is continually advancing, with the possibility of paving the way for personalized medicine based on the microbiome.

Background: Capsule endoscopy (CE) has become a widespread modality for non-invasive evaluation of the gastrointestinal (GI) tract, with several CE models having been developed throughout the years. The aim of this systematic review and meta-analysis is to evaluate performance measures such as completion, detection and retention rates of CE. Methods: Literature through to August 2021 was screened for articles regarding all capsule types: small bowel, double-headed capsule for the colon or PillCam®Crohn’s capsule, magnetically-controlled capsule endoscopy, esophageal capsule and patency capsule. Primary outcomes included detection rate (DR), completion rate (CR) and capsule retention rate (RR). DR, CR and RR were also analyzed in relation to indications such as obscure GI bleeding (OGIB), known/suspected Crohn’s disease (CD), celiac disease (CeD), neoplastic lesions (NL) and clinical symptoms (CS). Results: 328 original articles involving 86,930 patients who underwent CE were included. OGIB was the most common indication (n = 44,750), followed by CS (n = 17,897), CD (n = 11,299), NL (n = 4989) and CeD (n = 947). The most used capsule type was small bowel CE in 236 studies. DR, CR and RR for all indications were 59%, 89.6% and 2%, respectively. According to specific indications: DR were 55%, 66%, 63%, 52% and 62%; CR were 90.6%, 86.5%, 78.2%, 94% and 92.8%; and RR were 2%, 4%, 1%, 6% and 2%. Conclusions: Pooled DR, CR and RR are acceptable for all capsule types. OGIB is the most common indication for CE. Technological advancements have expanded the scope of CE devices in detecting GI pathology with acceptable rates for a complete examination.

BACKGROUND:Chronic diseases, such as IBD, can lead to anxiety and depression which can have a significant impact on productivity at work [presenteeism]. The aim of this study was to assess the prevalence of depression/anxiety, presenteeism and exercise levels among IBD patients.METHODS:This was a multicentre study whereby adult IBD patients, in clinical remission, were asked to answer a questionnaire anonymously. Hospital Anxiety and Depression Score [HADS], Stanford Presenteeism Scale [SPS-6] and Godin Exercise Score were also collected.RESULTS:A total of 585 patients were recruited. The majority had Crohn's disease [CD, 62.2%] and were male [53.0%], with a median age of 39 years [IQR 30-49]. A psychiatric diagnosis was present in 10.8% of patients prior to their IBD diagnosis. A further 14.2% of patients were psychiatrically diagnosed after IBD diagnosis, this being commoner in CD patients [41.6% of CD, p <0.01]. A raised HADS-Anxiety or a HADS-Depression score ≥8 was present in 46.1% of patients, with 27.4% having a score ≥11. Low presenteeism at work was present in 34.0%. Patients diagnosed with depression/anxiety had a more sedentary lifestyle [p <0.01], lower presenteeism at work [p <0.01] and a higher rate of unemployment [p <0.01].CONCLUSIONS:A significant percentage of IBD patients in remission suffer from anxiety and/or depression. Risk factors for these are CD, female gender, use of biologic medications, long-standing and/or perianal disease. Depression/anxiety was associated with a sedentary lifestyle, lower presenteeism at work and unemployment. Validated screening tools and appropriate referrals to psychologists and/or psychiatrists should be employed within IBD clinics.

AIMS:The primary aim of this study was to assess the reliability, intra- and inter-observer variation of the SPICE, Mucosal protrusion angle (MPA) and SHYUNG scores in differentiating a subepithelial mass (SEM) from a bulge. METHODS:This retrospective multicentre study analysed the 3 scores, radiological studies, enteroscopy and/or surgical findings. RESULTS:100 patients with a potential SEM (mean age 57.6years) were recruited with 75 patients having pathology. In patients with a SEM the mean SPICE score was 2.04 (95% CI 1.82-2.26) as compared to 1.16 (95% CI 0.81-1.51) without any pathology (AUC 0.74, p<0.001), with a fair intra-observer agreement (Kappa 0.3, p<0.001) and slight inter-observer agreement (Kappa 0.14, p<0.05). SPICE had a 37.3% sensitivity and 92.0% specificity in distinguishing between a SEM and bulge, whereas MPA<90˚ had 58.7% and 76.0% respectively, with poor intra-observer(p = 0.05) and interobserver agreement (p = 0.64). The SHYUNG demonstrated a moderate intra-observer (Kappa 0.44, p<0.001) and slight inter-observer reliability (Kappa 0.18, p<0.001). The sensitivity of an elevated SHYUNG score (≥4) in identifying a SEM was 18.7% with a specificity of 92.0% (AUC 0.71, p = 0.002). CONCLUSIONS:Though these scores are easy to use, they have, at best, slight to moderate intra and inter-observer agreement. Their overall diagnostic performances are limited.

AbstractCapsule endoscopy (CE) emerged out of the pressing clinical need to image the small bowel (SB) in cases of midgut bleeding and provide an overall comfortable and reliable gastrointestinal (GI) diagnosis 1. Since its wider adoption in clinical practice, significant progress has been made in several areas including software development, hardware features and clinical indications, while innovative applications of CE never cease to appear 2 3. Currently, several manufacturers provide endoscopic capsules with more or less similar technological features 4. Although there is engaging and continuous academic and industry-fueled R&D, promising furtherment of CE technology 4 5, the current status of clinical CE remains that of by and large an imaging modality. Clinical relevance of CE images is cornerstone in the decision-making process for medical management. In one of the larger to date SB CE studies, 4,206 abnormal images were detected in 3,280 patients 6. Thus, CE leads to the identification of a large amount of potential pathology, some of which are pertinent (or relevant) while some (probably the majority) are not.Soon artificial intelligence (AI) is likely to carry out several roles currently performed by humans; in fact, we are witnessing only the first stages of a transition in the clinical adoption of AI-based solutions in several aspects of gastroenterology including CE 7. Until then though, human-based decision-making profoundly impacts patient care and – although not suggested in the updated European Society of Gastrointestinal Endoscopy (ESGE) European curriculum 8 9 – it should be an integral part of CE training. Frequently, interpretation of CE images by experts or at least experienced readers differs. In a tandem CE reading study, expert review of discordant cases revealed a 50 % (13/25 discordant results) error rate by experienced readers, corresponding (in 5/13 cases) to ‘over-classification’ of an irrelevant abnormality 10. Another comparative study showed an ‘over-classification’ of such irrelevant abnormalities in ~10 % of CE readings 11. One thing which has been for a while on the table – in relation to optimizing and/or standardizing CE reporting and subsequent decision-making – is the need for reproducible scoring systems and for a reliable common language among clinicians responsible for further patient’s management.Over the years, several of these scoring systems were developed while others appear in the wake of software and hardware improvements aiming to replace and/or complement their predecessors. This review presents a comprehensive account of the currently available classification/scoring systems in clinical CE spanning from predicting the bleeding potential of identified SB lesions (with emphasis on vascular lesions), and the individual rebleeding risk; scoring systems for the prediction of SB lesions in patients with obscure gastrointestinal bleeding (OGlB), having the potential to improve patient selection and rationalize the use of enteroscopy, with better allocation of resources, optimized diagnostic workflow and tailored treatment. This review also includes scores for reporting the inflammatory burden, the cleansing level that underscores confidence in CE reporting and the mass or bulge question in CE. Essentially, the aim is to become a main text for reference when scoring is required and facilitate the inclusion of -through readiness of access- one of the other in the final report.

Capsule endoscopy (CE) emerged out of the pressing clinical need to image the small bowel (SB) in cases of midgut bleeding and provide an overall comfortable and reliable gastrointestinal (GI) diagnosis 1. Since its wider adoption in clinical practice, significant progress has been made in several areas including software development, hardware features and clinical indications, while innovative applications of CE never cease to appear 2 3. Currently, several manufacturers provide endoscopic capsules with more or less similar technological features 4. Although there is engaging and continuous academic and industry-fueled R&D, promising furtherment of CE technology 4 5, the current status of clinical CE remains that of by and large an imaging modality. Clinical relevance of CE images is cornerstone in the decision-making process for medical management. In one of the larger to date SB CE studies, 4,206 abnormal images were detected in 3,280 patients 6. Thus, CE leads to the identification of a large amount of potential pathology, some of which are pertinent (or relevant) while some (probably the majority) are not. Soon artificial intelligence (AI) is likely to carry out several roles currently performed by humans; in fact, we are witnessing only the first stages of a transition in the clinical adoption of AI-based solutions in several aspects of gastroenterology including CE 7. Until then though, human-based decision-making profoundly impacts patient care and – although not suggested in the updated European Society of Gastrointestinal Endoscopy (ESGE) European curriculum 8 9 – it should be an integral part of CE training. Frequently, interpretation of CE images by experts or at least experienced readers differs. In a tandem CE reading study, expert review of discordant cases revealed a 50 % (13/25 discordant results) error rate by experienced readers, corresponding (in 5/13 cases) to ‘over-classification’ of an irrelevant abnormality 10. Another comparative study showed an ‘over-classification’ of such irrelevant abnormalities in ~10 % of CE readings 11. One thing which has been for a while on the table – in relation to optimizing and/or standardizing CE reporting and subsequent decision-making – is the need for reproducible scoring systems and for a reliable common language among clinicians responsible for further patient’s management. Over the years, several of these scoring systems were developed while others appear in the wake of software and hardware improvements aiming to replace and/or complement their predecessors. This review presents a comprehensive account of the currently available classification/scoring systems in clinical CE spanning from predicting the bleeding potential of identified SB lesions (with emphasis on vascular lesions), and the individual rebleeding risk; scoring systems for the prediction of SB lesions in patients with obscure gastrointestinal bleeding (OGlB), having the potential to improve patient selection and rationalize the use of enteroscopy, with better allocation of resources, optimized diagnostic workflow and tailored treatment. This review also includes scores for reporting the inflammatory burden, the cleansing level that underscores confidence in CE reporting and the mass or bulge question in CE. Essentially, the aim is to become a main text for reference when scoring is required and facilitate the inclusion of -through readiness of access- one of the other in the final report.

[This corrects the article DOI: 10.1055/a-1372-4051.].

Capsule endoscopy (CE) emerged out of the pressing clinical need to image the small bowel (SB) in cases of midgut bleeding and provide an overall comfortable and reliable gastrointestinal ( GI) diagnosis [1]. Since its wider adoption in clinical practice, significant progress has been made in several areas including software development, hardware features and clinical indications, while innovative applications of CE never cease to appear [2, 3]. Currently, several manufacturers provide endoscopic capsules with more or less similar technological features [4]. Although there is engaging and continuous academic and industry-fueled R&D, promising furtherment of CE technology [4, 5], the current status of clinical CE remains that of by and large an imaging modality. Clinical relevance of CE images is cornerstone in the decision- making process for medical management. In one of the larger to date SB CE studies, 4,206 abnormal images were detected in 3,280 patients [6]. Thus, CE leads to the identification of a large amount of potential pathology, some of which are pertinent (or relevant) while some (probably the majority) are not. Soon artificial intelligence (AI) is likely to carry out several roles currently performed by humans; in fact, we are witnessing only the first stages of a transition in the clinical adoption of AI-based solutions in several aspects of gastroenterology including CE [7]. Until then though, human-based decision-making profoundly impacts patient care and -although not suggested in the updated European Society of Gastrointestinal Endoscopy (ESGE) European curriculum [8, 9] -it should be an integral part of CE training. Frequently, interpretation of CE images by experts or at least experienced readers differs. In a tandem CE reading study, expert review of discordant cases revealed a 50% (13/25 discordant results) error rate by experienced readers, corresponding (in 5/13 cases) to 'over-classification' of an irrelevant abnormality [10]. Another comparative study showed an 'over-classification' of such irrelevant abnormalities in similar to 10% of CE readings [11]. One thing which has been for a while on the table -in relation to optimizing and/or standardizing CE reporting and subsequent decision-making -is the need for reproducible scoring systems and for a reliable common language among clinicians responsible for further patient's management. Over the years, several of these scoring systems were developed while others appear in the wake of software and hard-ware improvements aiming to replace and/or complement their predecessors. This review presents a comprehensive account of the currently available classification/scoring systems in clinical CE spanning from predicting the bleeding potential of identified SB lesions (with emphasis on vascular lesions), and the individual rebleeding risk; scoring systems for the prediction of SB lesions in patients with obscure gastrointestinal bleeding (OGlB), having the potential to improve patient selection and rationalize the use of enteroscopy, with better allocation of resources, optimized diagnostic workflow and tailored treatment. This review also includes scores for reporting the inflammatory burden, the cleansing level that underscores confidence in CE reporting and the mass or bulge question in CE. Essentially, the aim is to become a main text for reference when scoring is required and facilitate the inclusion of -through readiness of access- one of the other in the final report.

Capsule endoscopy (CE) emerged out of the pressing clinical need to image the small bowel (SB) in cases of midgut bleeding and provide an overall comfortable and reliable gastrointestinal (GI) diagnosis 1. Since its wider adoption in clinical practice, significant progress has been made in several areas including software development, hardware features and clinical indications, while innovative applications of CE never cease to appear 2 3. Currently, several manufacturers provide endoscopic capsules with more or less similar technological features 4. Although there is engaging and continuous academic and industry-fueled R&D, promising furtherment of CE technology 4 5, the current status of clinical CE remains that of by and large an imaging modality. Clinical relevance of CE images is cornerstone in the decision-making process for medical management. In one of the larger to date SB CE studies, 4,206 abnormal images were detected in 3,280 patients 6. Thus, CE leads to the identification of a large amount of potential pathology, some of which are pertinent (or relevant) while some (probably the majority) are not. Soon artificial intelligence (AI) is likely to carry out several roles currently performed by humans; in fact, we are witnessing only the first stages of a transition in the clinical adoption of AI-based solutions in several aspects of gastroenterology including CE 7. Until then though, human-based decision-making profoundly impacts patient care and – although not suggested in the updated European Society of Gastrointestinal Endoscopy (ESGE) European curriculum 8 9 – it should be an integral part of CE training. Frequently, interpretation of CE images by experts or at least experienced readers differs. In a tandem CE reading study, expert review of discordant cases revealed a 50 % (13/25 discordant results) error rate by experienced readers, corresponding (in 5/13 cases) to ‘over-classification’ of an irrelevant abnormality 10. Another comparative study showed an ‘over-classification’ of such irrelevant abnormalities in ~10 % of CE readings 11. One thing which has been for a while on the table – in relation to optimizing and/or standardizing CE reporting and subsequent decision-making – is the need for reproducible scoring systems and for a reliable common language among clinicians responsible for further patient’s management. Over the years, several of these scoring systems were developed while others appear in the wake of software and hardware improvements aiming to replace and/or complement their predecessors. This review presents a comprehensive account of the currently available classification/scoring systems in clinical CE spanning from predicting the bleeding potential of identified SB lesions (with emphasis on vascular lesions), and the individual rebleeding risk; scoring systems for the prediction of SB lesions in patients with obscure gastrointestinal bleeding (OGlB), having the potential to improve patient selection and rationalize the use of enteroscopy, with better allocation of resources, optimized diagnostic workflow and tailored treatment. This review also includes scores for reporting the inflammatory burden, the cleansing level that underscores confidence in CE reporting and the mass or bulge question in CE. Essentially, the aim is to become a main text for reference when scoring is required and facilitate the inclusion of -through readiness of access- one of the other in the final report.

Crohn's disease (CD) is a lifelong, chronic inflammatory bowel disorder. The small bowel (SB) is involved to varying extents, and the clinical course may vary from an inflammatory type to a more complicated one with stricture, fistula, and abscess formation. Esophagogastroduodenoscopy and ileocolonoscopy with biopsies are the conventional endoscopic techniques that usually establish the diagnosis. On the other hand, CD may affect SB segments that cannot be reached through these procedures. Video capsule endoscopy and enteroscopy are additional endoscopic techniques that may allow further SB evaluation in such circumstances. Computed tomographic enterography, magnetic resonance enterography, and ultrasonography are radiologic techniques that serve as a crucial adjunct to endoscopic assessment. They enable the assessment of parts of the bowel that may be difficult to reach with conventional endoscopy; this allows for the detection of active inflammation, penetrating or stricturing disease, and the appreciation of extraintestinal complications. Both endoscopic and radiologic modalities play a role in establishing the diagnosis of CD, as well as determining the disease extent, activity and response to therapy. This review is intended to evaluate these modalities in terms of specificity, sensitivity, potential side-effects, and limiting factors. This should serve as a guide to the clinician for establishing the most appropriate and reliable test within a particular clinical context.