United European Gastroenterology Journal最新文献

Introduction: Since the publication of the first European Society for the Study of Coeliac Disease (ESsCD) guidelines in 2019, substantial advances have been made in understanding the management and complex disease courses of coeliac disease (CeD) in adults. These 2025 updated guidelines aim to integrate new evidence, refine management strategies, and promote a personalised and multidisciplinary approach to care.

Methods: The ESsCD convened a multidisciplinary panel of experts to revise the 2019 guidelines using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) framework. Evidence was appraised and graded according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. Statements and recommendations were draughted within working groups and finalised through a structured Delphi consensus process.

Results: The updated guidelines are presented in two parts. Part 1, which has already been published, addresses the diagnostic approach to CeD in adults, whereas Part 2 focuses on disease management, structured follow-up, and the evaluation and treatment of persistent symptoms despite a gluten-free diet or refractory disease. New or expanded sections include guidance on the safe inclusion of oats, use of low-FODMAP diets in patients with persistent symptoms, management of exocrine pancreatic insufficiency, recognition of functional asplenia and related vaccination recommendations, and stratified bone-health screening. The guidelines also discuss nutritional and psychosocial support, digital models of care, and structured transition from paediatric to adult services. Updated therapeutic strategies for refractory CeD are provided, including immunosuppressive and novel pharmacologic options.

Conclusions: These updated guidelines offer a comprehensive, evidence-based framework for the management and follow-up of adults with CeD. By integrating recent scientific advances with pragmatic, patient-centred recommendations, they seek to optimise clinical outcomes, quality of life, and long-term health in individuals with CeD.

Introduction: Learning curve of EUS-guided Gastroenterostomy (EUS-GE) has been explored through retrospective studies involving few elite senior endoscopists (SE), with procedural time as the main surrogate outcome. This study aims to evaluate the training of junior endoscopists (JE) approaching the technique and cover clinically relevant patient outcomes.

Methods: From a prospective single-center registry (PROTECT, ClinicalTrials.gov NCT04813055) of EUS-GE for malignant Gastric Outlet Obstruction using the Wireless Simplified [WEST] technique, the learning curve of 3 JE experienced in pancreatobiliary endoscopy was analyzed to identify changing points ("knots") applying linear and spline regression and cumulative sum control chart (CUSUM) on several continuous and dichotomic variables. EUS-GE performed by a SE and different indications were excluded.

Results: From a database of 165 EUS-GEs, 100 were performed by one novice endoscopist with prior EUS-GE exposure (JE1) and 35 by two naïve endoscopists (JE2/JE3). On the largest curve (JE1), procedural time and fluoroscopy time did not show any improvement. The use of fluoroscopy (median Air Kerma: 267 Gy [172-506]) showed a significant improvement after 57 interventions (spline regression) and 72 interventions (CUSUM), after which the curve stabilized. The need for supervision/backup of a SE showed a knot after 32 interventions. Technical success (99%), Clinical success (96%), Misdeployments (2%) and AEs (6%) were stable along the learning curve. Conversion from EUS-GE to enteral stenting (11%) tended to decrease over time. Despite naïve endoscopists required significantly higher fluoroscopy time (234 vs. 187 s, p = 0.009) and procedural time (55 vs. 43 min, p = 0.002) than JE1, efficacy and safety outcomes were not different from the general cohort.

Conclusions: From a prospective registry, ≈30 EUS-GE seems required for independent practice, and ≈55-70 to minimize and stabilize the use of fluoroscopy. Endoscopists learning EUS-GE in high-volume institutions using a standardized technique do not compromise high clinical and safety standards.

Background: Although the current strategy in ulcerative colitis (UC) focuses on achieving endoscopic healing to improve long-term outcomes, patients with persistent microscopic inflammation or intestinal barrier dysfunction remain at increased risk of relapse.

Objective: We evaluated whether structural and functional abnormalities of the ileal and colonic mucosa assessed by probe-based Confocal laser Endomicroscopy (pCLE) could predict the loss of therapeutic targets.

Methods: The prospective single-center study included 81 UC patients in clinical and endoscopic remission monitored for 24 months. At baseline, barrier dysfunction and histological inflammation (HI) were assessed through colonoscopy with pCLE and targeted biopsies from the terminal ileum, ascending colon, sigmoid, and rectum. Clinical evaluations were performed every 3 months.

Results: The main predictors of loss of endoscopic remission were altered colonic permeability (Odds ratio OR = 3.85, 95% confidence interval CI 1.25-11.77, p = 0.018) and HI detected by pCLE (OR = 6.04, 95% CI 1.89-19.31, p = 0.002). Survival analysis demonstrated an increased risk of clinical relapse in patients with an altered barrier in the terminal ileum (Hazard ratio HR = 6.01, 95% CI 3.08-16.38, p < 0.001) or colon (HR = 6.51, 95% CI 2.08-17.21, p < 0.001). Persistent microscopic inflammation (Enhance index > 1) was significantly associated with unfavorable clinical outcome (HR = 3.39, 95% CI 1.23-8.38, p = 0.018). None of the 29 patients diagnosed with triple healing (histological healing associated with intact ileal and colonic permeability) at inclusion experienced relapse.

Conclusions: Morphological and functional evaluation using pCLE offers superior prognostic value and is emerging as a possible therapeutic target for the prevention of clinical and endoscopic relapses in UC.

Background: Most gastric cancer cases are attributable to chronic Helicobacter pylori (H. pylori) infection and can theoretically be prevented.

Objective: In the EUROHELICAN project, we aimed to assess the feasibility, acceptability, effectiveness, and adverse events of a Helicobacter pylori screen-and-treat program in the 30-34-year age group for the first time in Europe.

Design: The study was conducted in the Community Healthcare Center dr. Adolf Drolc Maribor, following the methodology prepared by the National Institute of Public Health. We invited asymptomatic individuals aged 30-34 to be tested for H. pylori IgG antibodies; positive results were confirmed by urea breath test (UBT).

Results: 2102 participants accepted the invitation. The response rate was 24.4% (95% CI: 23.2-25.5), which was higher in women-28.1% (95% CI: 26.4-29.8) than in men-20.5% (95% CI: 0.19.0-22.1, p < 0.001). The serological prevalence of H. pylori infection was 14.2% (95% CI: 12.7-15.9). A confirmatory urea breath test (UBT) was positive in 83.7% of serology-positive patients. The eradication rate of 14-day bismuth-based quadruple therapy (esomeprazole 40 mg BID, amoxicillin 500 mg, metronidazole 400 mg and bismuth oxide 120 mg, all QID) was 94.7% (95% CI: 89.5-97.9). Adverse events (AEs) during treatment were reported more frequently in women (38.8%, 95% CI: 28.1-50.3) than in men (21.5%, 95% CI: 12.3-33.5; p < 0.05).

Conclusion: H. pylori screening and-treat program in 30-34 age group in Slovenia is feasible; H. pylori treatment is very effective with acceptable rate of AEs. Different approaches to raising public awareness are needed to increase participation rates.

Trial registration: EU PAS number of HMA-EMA RWD Catalog: EUPAS107327, Study ID: 108428; ClinicalTrials.gov ID: NCT06216639, Protocol ID: EUROHELICAN01.

Background: The current guidelines recommend cold snare polypectomy (CSP) for removing intermediate-size sessile serrated lesions (SSLs) measuring 10-20 mm. However, these supporting data come from single-arm or retrospective studies, underscoring the need for randomized controlled trials to confirm its efficacy. This study aimed to compare the efficacy of CSP and cold endoscopic mucosal resection (EMR) with that of hot EMR in achieving complete histological resection of intermediate-size SSLs.

Methods: This was a multicenter, randomized, non-inferiority trial. A total of 113 patients with 159 intermediate-size SSLs were randomized into three groups: CSP, cold EMR, and hot EMR. The primary outcome was the complete histological resection, defined as tumor-free horizontal and vertical margins, regardless of whether resection was en bloc or piecemeal. Secondary outcomes included en bloc resection rate, polypectomy time, and procedural complications.

Results: The complete histological resection rates were 90.6% for CSP, 88.5% for cold EMR, and 87.0% for hot EMR, demonstrating the non-inferiority of CSP and cold EMR compared to hot EMR. CSP had a shallower vertical resection depth, which was improved by submucosal injection. CSP also had shorter polypectomy and total procedure times. The En bloc resection rates were 69.8% for CSP, 78.9% for cold EMR, and 88.9% for hot EMR. Although the en bloc resection rate was lower with CSP compared with hot EMR, it improved with submucosal injection.

Discussion: CSP and cold EMR are effective alternatives to hot EMR for removing intermediate-size SSLs, providing strong support for their recommendations in guidelines. Further research is warranted to evaluate the long-term residual rate.

Background: We aimed to determine corticosteroid (CS) use in paediatric inflammatory bowel disease (PIBD, < 18 years), which remains common despite recommendations for limited use and the emergence of steroid-sparing therapies.

Methods: We conducted a study of all children in Sweden diagnosed with CD (n = 2460) or UC (n = 2470) in 2006-2022. Nationwide health registers provided annual individual-level data on CS use, classified as any use and excess use (i.e., ≥ 2 courses or ≥ 3 months of use per year).

Results: The mean age at diagnosis was 13.7 (SD = 3.4) for CD and 13.9 (SD = 3.8) years for UC. In CD, the proportion of patients with any annual CS use decreased from 42.9% (2006) to 27.6% (2022; p < 0.001), particularly for excess CS use (decreasing from 33.7% to 19.1%; p < 0.001). Rates in UC remained largely unchanged, with any CS use at 41.0% in 2006 and 43.6% in 2022 (p = 0.43), while excess use was 32.4% in 2006 and 36.2% in 2022 (p = 0.21). Although any CS use was most common during the first year after diagnosis (CD: 63.8%, UC: 70.6%), annual rates stabilised only during the fourth (CD) and fifth (UC) years of diagnosis. Older age at diagnosis and prior IBD-related hospitalisation were risk factors for excess CS use in both CD and UC.

Conclusions: The use of CS in PIBD remains high, with annual rates showing no reduction in UC over the past more than 15 years, while a marked decline is observed in CD. Our data should inform strategies to reduce excess CS use in children.

Introduction: Obstruction of the pancreatic duct by impacted gallstones at the level of the papilla vateri causes acute pancreatitis. How non-obstructing stones such as microlithiasis or sludge cause pancreatitis has not been studied. We aimed to understand the pathomechanism of microlithiasis-induced acute pancreatitis.

Methods: In human papillary biopsies from patients with microlithiasis-induced acute pancreatitis (n = 4), alcohol-induced acute pancreatitis (n = 5), and control subjects without pancreatobiliary disease (n = 4), the inflammatory infiltrate was quantified. Bone marrow-derived macrophages generated from C57BL/6 mice were treated in vitro with cholesterol monohydrate and calcium bilirubinate crystals, and NLRP3 inflammasome-mediated macrophage activation was quantified. Microlithiasis formation in the gallbladder was induced in mice through lithogenic high fat diet and devazepide. Acute pancreatitis was induced by supramaximal caerulein stimulation. Microlithiasis ejection from the gallbladder was achieved through low-dose caerulein i.p. Injections. Pancreatitis severity was compared between caerulein-induced pancreatitis and caerulein-induced pancreatitis after repetitive microlithiasis ejection.

Results: Significantly higher infiltration of CD45-positive leukocytes and increased NLRP3 expression were observed in papillary biopsies from patients with microlithiasis-induced acute pancreatitis compared with patients with alcohol-induced acute pancreatitis and control subjects. In line with this, significantly higher IL-1ß secretion and caspase-1 activation were observed in vitro in bone marrow-derived macrophages stimulated with cholesterol monohydrate and calcium billirubinate crystals. In vivo microlithiasis formation was achieved in all mice with high fat diet and devazepide. Compared to caerulein-induced pancreatitis, in caerulein + microlithiasis pancreatitis, higher LDH, GPT and ALP levels in serum were observed, but without an impact on pancreatitis severity. However, mice papilla mimicked the phenotype of microlithiasis-induced acute pancreatitis in humans.

Conclusion: We propose a novel mechanism in which biliary microlithiasis induces a local inflammatory reaction at the papilla (acute papillitis) via NLRP3 inflammasome activation driven by bone marrow-derived macrophages, without causing pancreatic outflow obstruction.