Background and aims Cirrhosis progression from compensated to decompensated stage signals a deterioration in prognosis, with episodes of acute decompensation (AD) carrying a high risk of short-term mortality. Recently, the concept of non-acute decompensation (NAD) has emerged, representing a more insidious form of decompensation that is nonetheless associated with increased mortality. We aimed to evaluate the clinical impact of NAD in a hospital-referred hepatology population. Methods Single-center, retrospective, longitudinal observational study which included adult patients with compensated cirrhosis followed between 2013-2025. Results Data from 391 patients were analyzed, 72.1% male with a mean age of 59.9±11 years. Of those, 215 did not decompensate (ND), 121 developed NAD and 55 developed AD. The baseline independent predictors of NAD included a higher MELD score, lower serum albumin and non-compliance with the effective etiological treatment. AD was predicted by lower serum albumin, lower platelet count and non-compliance with the effective etiological treatment. Mortality was significantly higher in NAD (HR 10.82; p<0.001) and AD (HR 21.47; p<0.001) when compared with ND. Conclusions Our data shows that both AD and NAD are independent predictors of mortality in cirrhosis, with the former associating more significantly than the latter. However, the occurrence of NAD, despite clinically silent, should be recognized as marker of poor prognosis.

BACKGROUND The optimal bowel preparation for small bowel capsule endoscopy (SBCE) has not been standardized. AIM To compare the rate of complete examinations, quality of bowel preparation, diagnostic yield and tolerability, using three protocols for SBCE. METHODS A prospective, multicentre, randomized study including patients submitted to SBCE was conducted. Patients ingested a booster once the capsule reached the small bowel, randomized into one of three protocols: (1) 1 L of polyethylene glycol (PEG); (2) 1 L of PEG and ascorbic acid; and (3) 1 L of water. The patients' bowel preparation was evaluated with Small Bowel CLEansing Assessment and Report. RESULTS A total of 261 patients were included, 96 (36.8%) in protocol 1, 93 (35.6%) in protocol 2 and 72 (27.6%) in protocol 3. The rate of complete examinations, adequate bowel preparation and diagnostic yield were comparable among the groups (P = 0.655, P = 0.193 and P = 0.589, respectively). The overall Small Bowel CLEansing Assessment and Report score was similar among the protocols (P = 0.236). Although the preparation of the third tertile had a lower score using protocol 3 (protocol 1: 2.5 +/- 0.1 vs 2: 2.6 +/- 0.1 vs 3: 2.3 +/- 0.1, P = 0.021), it did not compromise the mucosal visualization, maintaining a mean score above 2 and similar diagnostic yield among the protocols (P = 0.850). The patients' reported tolerability was higher in protocol 3 (protocol 1: 2.8 +/- 0.1 vs 2: 3.0 +/- 0.2 vs 3: 0.6 +/- 0.1, P < 0.001). CONCLUSION Using 1 L of water as a booster in SBCE was better tolerated and associated with comparable rates of complete examinations, adequate bowel preparation and diagnostic yield vs PEG with or without ascorbic acid.

INTRODUCTION:Early detection of gastric dysplastic lesions and early gastric cancer (EGC) is crucial to enable prompt treatments, such as endoscopic submucosal dissection (ESD). Understanding the distribution and characteristics of these lesions can enhance the efficiency of endoscopic examinations. This study aimed to analyze the locations and characteristics of dysplasia and EGCs in the stomach. METHODS:Retrospective study reviewing pathologically diagnosed gastric dysplasia and EGCs treated by ESD. Lesions were grouped by location (proximal-cardia, fundus, and body; distal-incisura and antrum) and compared regarding several clinicopathological variables. A predictive model - Search At the Top (SAT) score - was created using three pre-endoscopic variables: male sex (2 points), excessive alcohol consumption (1 point), and smoking (1 point). The score was evaluated for its ability to predict proximal lesions. RESULTS:A total of 215 patients were included (66.5% male; mean age 68 ± 8 years), with 225 lesions analyzed: 50.7% low-grade dysplasia, 30.7% high-grade dysplasia, and 18.6% adenocarcinoma. Most lesions were located in the distal stomach (73.3%) and along the lesser curvature (39.6%).Proximal lesions were more often associated to male sex (P = 0.001), younger age (P = 0.027), alcohol consumption (P = 0.003), and smoking (P = 0.008).The SAT-score showed moderate discriminative performance (area under the curve = 0.674) and identified high-risk patients (score ≥3) with 3.5-fold increased odds of having proximal lesions (odds ratio = 3.459; P < 0.001). CONCLUSION:Most gastric dysplastic lesions and EGCs were located in the distal stomach and along the lesser curvature. Proximal gastric lesions were more frequent in younger male patients with alcohol and tobacco exposure. These location-specific characteristics can enhance the diagnostic performance of endoscopic screening and surveillance, potentially leading to improved patient outcomes.

INTRODUCTION:the rate of adequate bowel preparation and complete examinations are crucial quality measures in colon capsule endoscopy (CCE). The aim of this study was to evaluate clinical and demographic factors possibly associated with inadequate bowel preparation in patients undergoing CCE. METHODS:retrospective cross-sectional study including consecutive patients submitted to CCE between September 2019 and August 2021. The primary outcome was the adequacy of bowel preparation, using the Colon Capsule CLEansing Assessment and Report (CC-CLEAR). Secondary outcomes included the rate of complete examinations and the presence of findings throughout the colon. RESULTS:a total of 202 patients were included, 140 (69.3 %) with adequate bowel preparation and 62 patients (30.7 %) with inadequate bowel preparation. Patients with diabetes mellitus or hypothyroidism were more likely to have inadequate bowel preparation (OR 2.247, 95 % CI: 1.115-4.525, p = 0.022, and OR 3.226, 95 % CI: 1.143-9.091, p = 0.044, respectively), as well as smokers and patients on psychotropic drugs, namely benzodiazepines and/or antidepressants (OR 3.115, 95 % CI: 1.381-7.042, p = 0.005, and OR 1.916, 95 % CI: 1.041-3.521, p = 0.036, respectively). The adequacy of bowel preparation was not associated with the detection of findings (right p = 0.928, transverse p = 0.967 and left colon p = 0.632), similarly to the rate of complete examinations (p = 0.100). According to multivariable analysis, diabetes mellitus (OR 2.451, 95 % CI: 1.153-5.208, p = 0.020), hypothyroidism (OR 3.269, 95 % CI: 1.095-9.755, p = 0.034), smoking (OR 4.115, 95 % CI: 1.721-9.840, p = 0.001) and being on psychotropic drugs (OR 2.344, 95 % CI: 1.200-4.577, p = 0.013) were independent predictive factors for inadequate bowel preparation. CONCLUSION:diabetes mellitus, hypothyroidism, active smoking and the use of psychotropic drugs were identified as predictors of inadequate bowel preparation in CCE. In such patients, the bowel preparation regimen should be optimized to enhance the quality and diagnostic yield of CCE.

OBJECTIVE:Crohn's disease (CD) is heterogeneous, and proximal involvement in the small bowel (SB) is associated with worse outcomes. Nonetheless, studies on the impact of duodenal and jejunal lesions in SB CD are limited. This study aimed to investigate the clinical characteristics and outcomes of individuals diagnosed with SB CD, comparing those with and without proximal inflammation. METHODS:A cohort of 53 treatment-naive SB CD patients that underwent Capsule Endoscopy at diagnosis were retrospectively selected. The inflammatory activity was quantified using the Lewis Score for each SB tertile. RESULTS:Thirty-seven (69.8%) patients displayed inflammatory activity in the first and/or second tertile together with third tertile involvement (Proximal+T3 group). Sixteen (30.2%) had inflammation in the third tertile only (T3 group). Individuals in the Proximal+T3 group had a higher risk for moderate-to-severe inflammation (OR 4.93, 95% CI: 1.3-18.3, p=0.013). A subgroup analysis for those with mild inflammatory activity showed that individuals in the Proximal+T3 group initiated biologic drugs more often (OR 11, 95% CI: 1.1-109.7, p=0.036). CONCLUSION:Proximal SB lesions are associated with increased inflammatory activity, necessitating more frequent use of biologics in patients with mild disease. Early detection of proximal SB CD with Capsule Endoscopy may contribute to timely treatment.

BACKGROUND AND AIM:We aimed to develop and validate a simple capsule endoscopy (CE) training assessment tool, the Capsule Endoscopy Training Assessment (CETA), and prospectively use it to analyze the learning progression achieved by participants in our CE training program. METHODS:Over a 3-year period, all participants in our CE training program completed pre-training and post-training CETA, ranging between 0% and 100%, and encompassing theoretical questions and interpretation of segmented CE videos. We compared the mean differences in overall, theoretical, and practical pre-training and post-training CETA, and assessed the influence of previous endoscopic experience (upper gastrointestinal endoscopy [UGE], colonoscopy, device-assisted enteroscopy [DAE] and CE) using generalized linear models. RESULTS:Fifty-seven participants were included. After training, there was a significant increase in participants' overall (mean difference, 26.3; 95% confidence interval [CI], 20.70 to 31.83), theoretical (mean difference, 27.2; 95% CI, 19.81 to 34.57), and practical (mean difference, 25.9; 95% CI, 20.09 to 31.63) CETA components. Compared to those without experience, participants with previous endoscopic experience demonstrated a smaller increase in overall CETA after training (UGE, rate ratio, 0.76; 95% CI, 0.63 to 0.91; colonoscopy (rate ratio, 0.80; 95% CI, 0.67 to 0.95; DAE (rate ratio, 0.84; 95% CI, 0.73 to 0.97; CE, rate ratio, 0.81; 95% CI, 0.72 to 0.92, respectively). CONCLUSION:CETA is a valid and useful tool in assessing the learning progression achieved by participants following the CE training program. We demonstrated a significant improvement in participants' CETA after training, being the least experienced participants in endoscopic procedures who benefited the most from CE training.

BACKGROUND:Recently, a formula of subcutaneous infliximab (SC-IFX) has been approved for inflammatory bowel disease (IBD), demonstrating a better pharmacokinetic and immunogenic profiles, compared to intravenous infliximab (IV-IFX), with similar efficacy and safety. AIM:The aim of this study is to evaluate the clinical, biochemical, and pharmacological outcomes of IBD patients in clinical remission, who switched from IV-IFX to SC-IFX, with a follow-up period of 6 months. METHODS:Retrospective cohort study, including IBD patients in clinical remission, previously medicated with IV-IFX, who switched to SC-IFX 120 mg every other week. Biochemical parameters were evaluated before the switch and 6 months after, namely infliximab serum concentrations, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and fecal calprotectin. RESULTS:Included 41 patients in clinical remission, 32 with Crohn's disease (78.0%) and 9 with ulcerative colitis (22.0%). All patients maintained clinical remission during the 6 months after the switch, with a treatment persistence rate of 100%, and no patients requiring corticosteroid therapy, switching back to IV-IFX, or IBD-related hospitalization. The mean infliximab serum concentrations were significantly higher after 6 months of SC-IFX (17.3 ± 6.6 vs. 9.1 ± 5.5 µg/ml, P  < 0.001). However, there were no differences between values of ESR, CRP, and fecal calprotectin, before and after the switch ( P  = 0.791, P  = 0.246, and P  = 0.639). Additionally, none of the patients developed antibodies to infliximab. CONCLUSION:Switching from IV-IFX to SC-IFX in IBD patients in clinical remission is effective and leads to higher infliximab serum concentrations, regardless of the combination with immunomodulatory therapy.

Aims There is scarce evidence regarding the outcomes of capsule endoscopy (CE) training programs and its impact amongst trainees. We aimed to analyze the impact of a CE training program on CE proficiency with a new developed CE training assessment tool, the pre and post Capsule Endoscopy Training Assessment (CETA). Additionally, we investigated whether prior experience in flexible endoscopic techniques or CE could influence participants' CETA mean score and achievement of a posttraining learning goal.

A 67-year-old female, without prior medical history, presented to the emergency department due to dizziness and asthenia, where iron deficiency anemia, without visible blood loss, was identified. A previous abdominal computed tomography revealed intestinal pneumatosis of the proximal jejunum and right colon. The upper endoscopy showed non-atrophic gastritis associated with H.pylori infection, which was treated, and the colonoscopy revealed right colic pneumatosis, without other alterations. A small bowel capsule endoscopy was performed, revealing bulging areas of the intestinal wall, lymphangiectasias and angioectasias, in the proximal small bowel. A single balloon assisted anterograde enteroscopy reached the proximal jejunum, showing several areas of bulging with endoscopically normal mucosa, compatible with intestinal pneumatosis. In 3 bulging areas, there were multiple lymphangiectasias and friable punctate angioectasias, which were treated with argon-plasma coagulation and through-the-scope clip with haemostatic success. The procedure was uneventful. After 6 months of follow-up, the patient was asymptomatic, without anemia or iron deficiency.

Colon capsule endoscopy (CCE) is a well-known method for the detection of colorectal lesions. Nevertheless, there are no studies reporting the accuracy of TOP 100, a CCE software tool, for the automatic detection of colorectal lesions in CCE. We aimed to evaluate the performance of TOP 100 in detecting colorectal lesions in patients submitted to CCE for incomplete colonoscopy compared with classic reading. A retrospective cohort study including adult patients submitted to CCE (PillCam COLON 2; Medtronic) for incomplete colonoscopy. Blinded for each other’s evaluation, one experienced reader analyzed the TOP 100 images and the other performed classic reading to identify colorectal lesions. Detection of colorectal lesions, namely polyps, angioectasia, blood, diverticula, erosions/ulcers, neoplasia, and subepithelial lesions was assessed and TOP 100 performance was evaluated compared with the gold standard (classic reading). A total of 188 CCEs were included. Prevalence of colorectal lesions, polyps, angioectasia, blood, diverticula, erosions/ulcers, neoplasia, and subepithelial lesions were 77.7, 54.3, 8.5, 1.6, 50.0, 0.5, 0.5, and 1.1%, respectively. TOP 100 had a sensitivity of 92.5%, specificity of 69.1%, negative predictive value of 72.5%, positive predictive value of 91.2%, and accuracy of 87.2% for detecting colorectal lesions. TOP 100 had a sensitivity of 89.2%, specificity of 84.9%, negative predictive value of 86.9%, positive predictive value of 87.5%, and accuracy of 87.2% in detecting polyps. All colorectal lesions other than polyps were identified with 100% accuracy by TOP 100. TOP 100 has been shown to be a simple and useful tool in assisting the reader in the prompt identification of colorectal lesions in CCE.

BACKGROUND Alpha-1 antitrypsin deficiency (AATD) is a codominant autosomal hereditary condition that predisposes patients to the development of lung and/or liver disease, and Pi*Z allele is the most clinically relevant mutation. AIM To evaluate the impact of clinical parameters and AATD phenotypes, particularly the Pi*Z allele, in liver fibrosis. METHODS Cross-sectional cohort study including consecutive patients with AATD followed in Pulmonology or Hepatology consultation. RESULTS Included 69 patients, 49.3% had Pi*MZ phenotype and 10.1% Pi*ZZ. An age ≥ 55 years, age at diagnosis ≥ 41 years and AAT at diagnosis < 77 mg/dL predicted a nonalcoholic fatty liver disease fibrosis score (NFS) not excluding advanced fibrosis [area under the curve (AUC) = 0.840, P < 0.001; AUC = 0.836, P < 0.001; AUC = 0.681, P = 0.025]. An age ≥ 50 years and age at diagnosis ≥ 41 years predicted a fibrosis-4 index of moderate to advanced fibrosis (AUC = 0.831, P < 0.001; AUC = 0.795, P < 0.001). Patients with hypertension, type 2 diabetes mellitus (DM), dyslipidaemia, metabolic syndrome, and regular alcohol consumption were more likely to have a NFS not excluding advanced fibrosis (P < 0.001, P = 0.002, P = 0.008, P < 0.001, P = 0.033). Patients with at least one Pi*Z allele and type 2 DM were 8 times more likely to have liver stiffness measurement ≥ 7.1 kPa (P = 0.040). CONCLUSION Risk factors for liver disease in AATD included an age ≥ 50 years, age at diagnosis ≥ 41 years, metabolic risk factors, regular alcohol consumption, at least one Pi*Z allele, and AAT value at diagnosis < 77 mg/dL. We created an algorithm for liver disease screening in AATD patients to use in primary care, selecting those to be referred to Hepatology consultation.

Gastroenterology Department, Hospital da Senhora da Oliveira, Portugal; Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Portugal; ICVS/3B's - PT Government Associate Laboratory, Portugal.

Aims Evaluate factors associated with upstaging and downstaging pathological results in gastric endoscopic submucosal dissection (ESD) specimens.

Objective To evaluate the risk factors for lymph node metastasis (LNM) after a non-curative (NC) gastric endoscopic submucosal dissection (ESD) and to validate and eventually refine the eCura scoring system in the Western setting. Also, to assess the rate and risk factors for parietal residual disease. Design Retrospective multicentre multinational study of prospectively collected registries from 19 Western centres. Patients who had been submitted to surgery or had at least one follow-up endoscopy were included. The eCura system was applied to assess its accuracy in the Western setting, and a modified version was created according to the results (W-eCura score). The discriminative capacities of the eCura and W-eCura scores to predict LNM were assessed and compared. Results A total of 314 NC gastric ESDs were analysed (72% high-risk resection (HRR); 28% local-risk resection). Among HRR patients submitted to surgery, 25% had parietal disease and 15% had LNM in the surgical specimen. The risk of LNM was significantly different across the eCura groups (areas under the receiver operating characteristic curve (AUC-ROC) of 0.900 (95% CI 0.852 to 0.949)). The AUC-ROC of the W-eCura for LNM (0.916, 95% CI 0.870 to 0.961; p=0.012) was significantly higher compared with the original eCura. Positive vertical margin, lymphatic invasion and younger age were associated with a higher risk of parietal residual lesion in the surgical specimen. Conclusion The eCura scoring system may be applied in Western countries to stratify the risk of LNM after a gastric HRR. A new score is proposed that may further decrease the number of unnecessary surgeries.

Aims Malignant colorectal polyps present a unique challenge due to their potential for metastasis. While complete endoscopic resection often achieves cure, comprehensive data on the characteristics influencing it remain limited. This study aimed to elucidate the key predictors associated with achieving endoscopic cure for malignant polyps.

Introduction: Propafenone is a widely used class Ic antiarrhythmic drug that is mainly metabolised by the liver. Hepatotoxicity associated with propafenone is rare, with only a few clinical cases reported in the literature. Case Presentation: We presented a case of propafenone-related hepatotoxicity, with cholestatic liver injury and development of jaundice and pruritus within 3 to 4 weeks of treatment initiation. Three months after discontinuation, the patient was asymptomatic, and all liver tests normalised. Conclusion: With this clinical case, we aimed to emphasise the importance of the medication history and the exclusion of other possible causes of altered liver enzymes.

Delayed bleeding (DB) is a possible adverse event following gastric endoscopic submucosal dissection (ESD). The BEST-J score was created as a risk prediction model for DB following gastric ESD, but is yet to be validated in Western populations. We aimed to validate the BEST-J score on a European sample and to perform a subgroup analysis according to histological classification. Retrospective study of all consecutive patients undergoing gastric ESD on a European Endoscopic Unit. DB was defined as hemorrhage with clinical symptoms and confirmed by emergency endoscopy from the time of completion to 28 days after ESD. BEST-J score was calculated in each patient and confronted with the outcome (DB). Final sample included 161 patients. From these, 10 (6.2

Background :Gastric dysplasia in the absence of an endoscopically defined lesion is rare, usually either a false positive diagnosis or a previously unidentified precancerous lesion during esophagogastroduodenoscopy (EGD).Aims: Evaluate factors associated with the presence of an endoscopically visible lesion during follow-up in patients with histologic diagnosis of gastric dysplasia in random biopsies.Methods: Retrospective cohort study including patients referred to our institution for gastric dysplasia in random biopsies during Index EGD. Endoscopic evaluation was performed with a high-definition endoscope using narrow band imaging (HD EGD-0). If no lesion was detected, endoscopic surveillance (HD EGD-FU) was conducted within 6 months for high grade dysplasia (HGD) or 12 months for low grade (LGD) or indefinite for dysplasia (IFD).Results: From a total sample of 96 patients, 5 (5.2%) presented with an endoscopically visible lesion during HD EGD-0, while 10 lesions (10.4%) were identified during HD EGD-FU. Patients with Helicobacter pylori infection at Index EDG and with regular alcohol consumption (>= 25 g/day) were 8 and 4 times more likely to have an endoscopically visible lesion on HD EGD-FU (p = 0.012 and p = 0.047). In binary logistic regression, both factors were independent predictors of the presence of gastric lesion on HD EGD-FU (OR 9.284, p = 0.009 and OR 5.025, p = 0.033).Conclusions: The presence of an endoscopically visible lesion after the histologic diagnosis of gastric dysplasia in random biopsies was more frequent during HD EGD-FU. H. pylori infection at Index EGD and regular alcohol consumption were significant predictors of the presence of gastric lesion on HD EGD-FU.