Digestion最新文献

Background: Endoscopic resection (ER) is a minimally invasive alternative to surgical resection for superficial non-ampullary duodenal epithelial tumors (SNADETs); however, it carries a high risk of adverse events (AEs) due to the thin duodenal wall and the technical challenges of endoscopic maneuverability. This review discusses the management of intraoperative and delayed postoperative AEs associated with duodenal ER.

Summary: Various ER techniques for SNADETs, including cold snare polypectomy (CSP), endoscopic mucosal resection (EMR), underwater EMR (UEMR), and endoscopic submucosal dissection (ESD), present different risk profiles. CSP has a very low risk of AEs, while EMR and UEMR exhibit moderate AE risks (up to 18.7%) and high recurrence rates, particularly in cases of piecemeal resections. ESD enables high en bloc resection rates but is associated with a considerable risk of AEs (up to 45.5%). Intraoperative AEs can be managed endoscopically using various closure techniques. To prevent intraoperative AEs during ESD, the use of scissor-type knives and specialized methods such as the pocket-creation method and water pressure method may be employed. Delayed AEs require effective closure of mucosal defects to prevent delayed perforation, which poses a high risk of conversion to surgical intervention.

Key messages: Careful patient selection and implementation of preventive strategies are essential to minimize AEs and optimize the safety of duodenal ER. A comprehensive understanding of the risk profiles of different ER techniques, along with appropriate preventive measures, is critical for safe and effective treatment. A multidisciplinary approach involving experienced endoscopists, surgeons, and radiologists is crucial to optimizing patient outcomes.

Background: The recognition of superficial non-ampullary duodenal epithelial tumors (SNADETs) has increased with advancements in endoscopic technology and increased awareness among clinicians. White light imaging (WLI) remains the primary diagnostic modality for SNADETs. However, data for standardized endoscopic diagnostic approaches are lacking.

Summary: SNADETs are typically identified by their whitish, flat-elevated appearance and are predominantly located in the descending duodenum. The whitish mucosa is referred to as milk white mucosa (MWM). Although biopsies are traditionally performed for the diagnosis, biopsies have limited sensitivity for histological grading and may cause submucosal fibrosis, which complicates subsequent endoscopic resection. SNADETs are classified as gastric, gastrointestinal, or intestinal mucin phenotypes. Gastric SNADETs are usually found in the pre-ampullary region and are typically lacking MWM, whereas intestinal-type SNADETs often exhibit MWM. Several endoscopic features under WLI, such as lesion color, size, surface depression, and morphology, are useful for predicting the grade of dysplasia. Features such as a submucosal tumor-like appearance, deep depression, and oral side location are important for assessing submucosal invasion.

Key messages: WLI plays an important role in the detection and initial assessment of SNADETs. Although differentiating SNADETs from other duodenal lesions using WLI alone remains challenging, understanding the endoscopic features associated with each mucin phenotype aids in accurate distinction of high-grade dysplasia from low-grade dysplasia. Future studies are warranted to establish a comprehensive endoscopic diagnostic system for SNADETs.

Introduction: Multichannel intraluminal impedance and pH monitoring (MII-pH) is the gold standard for diagnosing gastroesophageal reflux disease (GERD). However, the clinical value of the symptom-reflux association (SRA) obtained using MII-pH remains unknown. The current study aimed to investigate the effect of SRA on the efficacy of secondary treatment in refractory true GERD.

Methods: This study included patients who underwent MII-pH monitoring for evaluating proton pump inhibitor (PPI)- or potassium-competitive acid blocker (P-CAB)-refractory GERD symptoms and who were diagnosed with abnormal acid reflux (acid exposure time >6%). Patients with a positive symptom index (SI) and symptom association probability on the MII-pH monitoring were included in the SRA-positive group and the remaining ones in the SRA-negative group. The differences in the subsequent treatment efficacy between the two groups were retrospectively analyzed. Treatment efficacy was evaluated using the Frequency Scale for the Symptoms of GERD (FSSG) questionnaire.

Results: Of the 192 patients with PPI-/P-CAB-refractory GERD, 41 (21.4%) were diagnosed with abnormal acid reflux. Among them, 30 (7 in the SRA-positive group and 23 in the SRA-negative group) underwent symptom assessments before and after treatment. The SRA-positive group had a significantly greater symptom improvement after treatment compared with the SRA-negative group (FSSG score changes: -13.0 ± 6.5 vs. -5.4 ± 8.2, p = 0.016).

Conclusions: SRA evaluation is effective in predicting secondary treatment outcomes in patients with abnormal acid reflux.

Background: Gastroesophageal reflux disease (GERD) is a prevalent gastrointestinal disorder caused by the retrograde flow of gastric contents into the esophagus, leading to bothersome symptoms and complications. Its pathophysiology is complex and multifactorial, and recent research has aimed to explain the heterogeneity of GERD phenotypes, each influenced by different underlying mechanisms that contribute to symptom presentation and disease progression.

Summary: GERD arises from an imbalance between defensive mechanisms and disruptive factors. Key pathophysiological contributors include esophageal gastric junction dysfunction, transient lower esophageal sphincter relaxations, esophageal motility abnormalities, delayed gastric emptying, and thoracoabdominal pressure gradients. Mucosal damage is exacerbated by prolonged exposure to acid and bile, pepsin activity, and impaired esophageal volume and chemical clearance. Additionally, central and peripheral neural modulation influences symptom perception, with heightened visceral sensitivity and esophageal hypervigilance playing significant roles in symptom severity and treatment response. Emerging diagnostic techniques such as high-resolution manometry, impedance-pH monitoring, and EndoFLIP® are improving our ability to identify specific pathophysiological abnormalities, leading to more personalized approaches to GERD management.

Key messages: (i) GERD results from a multifactorial interplay between anatomical, functional, and neurophysiological mechanisms. (ii) Esophageal clearance, EGJ structure and function, acid exposure, mucosal resistance, and neural modulation are crucial determinants of symptom severity and disease progression. (iii) The presence of different phenotypes of the reflux disease (e.g., GERD, functional heartburn, and reflux hypersensitivity) underscores the need for individualized diagnostic and therapeutic strategies. (iv) Advances in diagnostic technologies enhance our understanding of GERD pathophysiology, facilitating tailored management approaches beyond acid suppression therapies. Future research should focus on refining GERD phenotyping and integrating mechanistic insights into personalized treatment paradigms.

Introduction: Non-ampullary duodenal epithelial tumors with a gastrointestinal mixed phenotype (mixed-type NADETs) have not been thoroughly analyzed. We aimed to elucidate the clinicopathological and endoscopic characteristics of mixed-type NADETs.

Methods: A total of 229 NADETs from 218 patients collected from February 2010 to December 2023 were analyzed. Based on immunohistochemistry for MUC5AC, MUC6, MUC2, and CD10, the NADETs were classified into gastric phenotype (GP), gastric predominant mixed phenotype (GPP), intestinal predominant mixed phenotype (IPP), and intestinal phenotype (IP).

Results: Among the 229 NADETs, there were 20, 22, 69, and 118 lesions classified as GP, GPP, IPP, and IP, respectively. Tumor location (first/second/third) was GP = 13/7/0, GPP = 12/8/2, IPP = 13/52/4, and IP = 16/94/8 (p < 0.01). Mean tumor sizes of GP, GPP, IPP, and IP were 14.7/18.5/10.9/10.3 mm (p < 0.01), respectively. The ratio of category 4/5 by Vienna classification was 50.0, 68.2, 13.0, and 2.5% (p < 0.01), respectively. In the comparisons between GP vs. GPP and IP vs. IPP, white opaque substance was significantly less frequently observed in GP than in GPP (p < 0.05), the ratio of category 4/5 was significantly higher in IPP than in IP (p < 0.01), but no significant differences were observed in tumor location, coloration, macroscopic type, and endoscopic findings including magnifying endoscopy with narrow-band imaging.

Conclusion: Mixed-type NADETs (GPP and IPP) exhibited similar endoscopic and clinicopathological characteristics to their predominant phenotypes, and may have a higher malignant potential than the pure phenotypes.

Introduction: We investigated the importance of skin microbiota in functional dyspepsia (FD) based on the skin-gut axis theory and revealed potential mechanisms. This study also validates recent popular FD treatments.

Methods: We used mendelian randomization (MR) to analyze 418 gut bacteria and 145 skin bacteria, identifying key symbionts in FD development. Bibliometric keyword analysis was conducted on current FD therapies. Finally, we used a mouse model of FD to assess body weight, food intake, gastric residue rate, small intestine transit rate, and fecal water content after interventions with skin-gut symbionts and treatment methods. Hematoxylin-eosin staining observed gastric antrum tissue morphology. RhoA and ROCK1 protein and mRNA levels in gastric antrum tissue were detected by western blot and real-time PCR. Fluorescence immunoassay observed ROCK1 and vesicular acetylcholine transporter (VAChT) protein expression.

Results: Streptococcus has a causal relationship with FD. Bibliometric analysis highlighted electroacupuncture as a research hotspot. Skin Streptococcus colonization reduced food intake, body weight, small intestine transit rate, and increased gastric residue rate in FD mice, decreasing RhoA, ROCK1, and VAChT protein and mRNA levels. Antibiotics reversed these effects. Electroacupuncture improved weight, appetite, gastrointestinal motility, and RhoA, ROCK1, and VAChT protein, and mRNA levels in FD mice.

Conclusion: The study confirmed the pathogenic role of skin Streptococcus in FD and the therapeutic value of electroacupuncture at Tianshu acupoint, potentially via RhoA/ROCK1 signaling pathway regulation.

Introduction: Vonoprazan (VPZ) therapy has become one of the standard treatments for gastroesophageal reflux disease (GERD). When GERD symptoms persist despite the maintenance dose therapy (10 mg daily), dose escalation to 20 mg daily is generally recommended. This study aims to clarify the proper timing and predictors for dose escalation of VPZ therapy in patients with refractory GERD treated with the maintenance dose.

Methods: This retrospective observational study included 257 patients with symptomatic GERD. Data from medical records, including endoscopic findings and Izumo scale scores, were analyzed.

Results: The mean follow-up period was 3.3 years. Throughout the follow-up period, VPZ dose escalation (from 10 to 20 mg daily) was required in 56 of 257 patients (22%). Kaplan-Meier analysis showed cumulative dose-escalation-free rates at 6 months, 1 year, and 2 years were 87%, 81%, and 78%, respectively. Predictive factors for VPZ dose escalation were analyzed using a Cox proportional-hazards regression model. Multivariate analysis revealed that pre-existing epigastric pain was a significant positive predictor for dose escalation, whereas pre-existing constipation was identified as a significant negative predictor. Kaplan-Meier analysis indicated that the 1-year dose-escalation-free rates were 69% in patients with epigastric pain compared to 88% in those without (p = 0.001). GERD symptom scores showed a significant improvement 1 month after dose escalation.

Conclusion: The incidence of refractory GERD requiring VPZ dose escalation is relatively low. Epigastric pain prior to VPZ initiation independently predicts the need for dose escalation. VPZ dose escalation effectively improves GERD symptoms.

Introduction: Oesophageal cancer is a leading global health issue, with increasing prevalence of oesophageal adenocarcinoma and its precursor lesion, Barrett's oesophagus (BE). Despite the opportunity to treat dysplasia prior to adenocarcinoma development, rates of missed advanced dysplasia at BE surveillance remain high. This pilot study aimed to assess whether Texture and Colour Enhancement Imaging (TXI), a new advanced mucosal imaging modality, improves dysplasia detection during BE surveillance compared to white light endoscopy (WLE).

Methods: Patients undergoing endoscopy for BE assessment or surveillance at a single centre were included for analysis. Patients were randomized in a 1:1 ratio to examination with WLE then TXI or vice versa, followed by narrow-band imaging (NBI). Targeted biopsies were taken from any suspicious areas and 4-quadrant surveillance biopsies were taken at 1 cm intervals in the entire BE segment.

Results: A total of 50 patients were included in the study, with 27 suspicious lesions seen in 22 patients. A total 93.3% (n = 14/15) of high-grade dysplasia or early adenocarcinoma was detected as endoscopically visible lesions on TXI and NBI. However, 4 such lesions were not detected on WLE. On per-patient analysis, the sensitivity and NPV of TXI in combination with magnified NBI were both 100% with specificity of 84.6%, surpassing all PIVI thresholds for dysplasia diagnosis in BE.

Conclusion: This pilot study demonstrates the feasibility of TXI as a potential addition to the armamentarium of advanced mucosal imaging available to proceduralists surveilling BE. Further large multi-centre studies would be required to make statistical comparisons with existing imaging modalities.

Background: Esophagogastroduodenoscopy is often performed as an initial examination in patients with symptoms such as dysphagia or chest pain, which may suggest esophageal motility disorders. However, its current role is largely limited to ruling out organic diseases.

Summary: High-resolution manometry (the gold standard for diagnosing primary esophageal motility disorders such as achalasia) along with esophagography is extremely useful for diagnosis. In recent years, however, several new endoscopic findings - esophageal rosette, gingko leaf sign, champagne glass sign, corona appearance, and pinstripe pattern - have been reported, making it increasingly possible to strongly suspect achalasia through endoscopy. Additionally, the presence of multiple annular contractions, spiral (corkscrew) contractions, or narrowing (poor distensibility) in the esophageal body during endoscopy may suggest abnormal motility of the esophageal body.

Key messages: When performing endoscopic examinations in patients with symptoms such as dysphagia or chest pain, it is important to consider the possibility of esophageal motility disorders. Careful endoscopic observation may allow for the suspicion of such disorders during the examination itself.

Introduction: Systemic sclerosis (SSc) causes esophageal motility disorders. However, esophageal symptom severity often does not correlate with the physiological findings of high-resolution manometry (HRM) in patients with SSc. Esophageal hypervigilance and visceral anxiety play a relevant role in symptom perception in patients with gastroesophageal reflux disease and esophageal motility disorders. Therefore, the present study examined the effects of anxiety and hypervigilance, along with HRM findings, on esophageal symptom severity in patients with SSc.

Methods: We reviewed the clinical data of consecutive patients with SSc who underwent HRM and were assessed using the esophageal hypervigilance and anxiety scale (EHAS) at our hospital between January 2022 and February 2025. Predictors for the Eckardt symptom score (ESS) and gastroesophageal reflux disease questionnaire (GerdQ) were investigated.

Results: This study included 51 patients with SSc. Significant differences were observed in EHAS scores between patients with ESS >3 and those with ESS ≤3 (34.0 [24.0-42.0] vs. 13.0 [1.0-24.0], p = 0.003), but not in HRM findings. The EHAS score accounted for 38.2% of the variance in the ESS score. Significant differences were also observed in the EHAS score between patients with GerdQ ≥8 and those with GerdQ <8 (26.0 [14.3-32.5] vs. 13.0 [0-22.0], p = 0.011). The combined factors of the EHAS score and absent contractility accounted for 17.3% of the variance in the GerdQ score.

Conclusion: Esophageal hypervigilance and anxiety may be involved in esophageal symptom severity, particularly dysphagia severity, in patients with SSc. Further studies involving interventions targeting these conditions, such as cognitive behavioral therapy, are warranted.