Linked-color imaging with or without artificial intelligence for adenoma detection: a randomized trial.

BACKGROUND: Adenoma detection rate (ADR) is an important indicator of colonoscopy quality and colorectal cancer incidence. Both linked-color imaging (LCI) with artificial intelligence (LCA) and LCI alone increase adenoma detection during colonoscopy, although it remains unclear whether one modality is superior. This study compared ADR between LCA and LCI alone, including according to endoscopists' experience (experts and trainees) and polyp size. METHODS: Patients undergoing colonoscopy for positive fecal immunochemical tests, follow-up of colon polyps, and abdominal symptoms at a single institution were randomly assigned to the LCA or LCI group. ADR, adenoma per colonoscopy (APC), cecal intubation time, withdrawal time, number of adenomas per location, and adenoma size were compared. RESULTS: The LCA (n=400) and LCI (n=400) groups showed comparable cecal intubation and withdrawal times. The LCA group showed a significantly higher ADR (58.8% vs. 43.5%; P<0.001) and mean (95%CI) APC (1.31 [1.15 to 1.47] vs. 0.94 [0.80 to 1.07]; P<0.001), particularly in the ascending colon (0.30 [0.24 to 0.36] vs. 0.20 [0.15 to 0.25]; P=0.02). Total number of nonpolypoid-type adenomas was also significantly higher in the LCA group (0.15 [0.09 to 0.20] vs. 0.08 [0.05 to 0.10]; P=0.02). Small polyps (≤5, 6-9mm) were detected significantly more frequently in the LCA group (0.75 [0.64 to 0.86] vs. 0.48 [0.40 to 0.57], P<0.001 and 0.34 [0.26 to 0.41] vs. 0.24 [0.18 to 0.29], P=0.04, respectively). In both groups, ADR was not significantly different between experts and trainees. CONCLUSIONS: LCA was significantly superior to LCI alone in terms of ADR.

Combined effects of granulocyte and monocyte adsorption apheresis and corticosteroids on ulcerative colitis.

Several new treatments for ulcerative colitis have been developed recently. The depletion of leukocytes by granulocyte and monocyte adsorption apheresis (GMA) was developed and adapted for patients with ulcerative colitis with rare adverse events. We investigated whether treatment with GMA and prednisolone (GMA + PSL) is more effective than PSL alone for patients with moderate to severe ulcerative colitis. Forty-seven patients with moderate to severe ulcerative colitis were retrospectively analyzed. Among the 47 patients, 27 received PSL, while 20 received GMA + PSL. The clinical activity of ulcerative colitis was evaluated using the Lichtiger clinical activity index (CAI) and serum levels of C-reactive protein. Mayo endoscopic score (MES) was used to examine endoscopic activity. The clinical remission rate was significantly higher in the GMA + PSL group than in the PSL group (65% vs 29.6%, p = 0.0206). The mucosal healing rate was also significantly higher in the GMA + PSL group than in the PSL group (60% vs 26%, p = 0.0343). The combination of GMA and steroids may be more effective than steroids alone for inducing clinical remission and mucosal healing in patients with moderate to severe ulcerative colitis.

Positive zinc intake and a Japanese diet rich in n-3 fatty acids induces clinical remission in patients with mild active ulcerative colitis: a randomized interventional pilot study.

Zinc intake has reduced hospitalizations in patients with ulcerative colitis (UC), highlighting the need to maintain blood zinc levels. This prospective study investigated whether the promotion of zinc intake and a Japanese diet (high in n-3 fatty acids) could induce clinical remission in patients with mild active UC. Patients with mild active UC were randomly assigned to either (1) continue an unrestricted diet or (2) receive nutritional guidance promoting zinc intake and a Japanese diet. The primary endpoint was clinical remission at 24 weeks. Secondary endpoints were the Ulcerative Colitis Endoscopic Index of Severity (UCEIS) scores, Clinical Activity Index (CAI), Geboes Histopathology Score (GHS), and biomarkers, including zinc levels, measured at 12 and 24 weeks. Nutritional assessments were performed using the Food Frequency Questionnaire. The CAI, UCEIS, and GHS scores were significantly lower in the intervention group than in the control group, with a significantly higher proportion of patients achieving clinical remission. Furthermore, the intervention group exhibited weight gain and significantly increased blood zinc levels. The combination of promoting dietary zinc intake and a Japanese diet rich in n-3 fatty acids can induce clinical remission in patients with mild active UC.

Endo-wing versus transparent hood-assisted colonoscopy for colorectal adenoma detection: A randomized controlled trial.

BACKGROUND AND AIM: This study aimed to compare the mean number of adenomas in patients undergoing Endo-wing-assisted colonoscopy (EAC) and transparent hood-assisted colonoscopy (TAC). METHODS: Patients undergoing colonoscopy for positive fecal immunochemical tests, colon polyp surveillance, and evaluation of abdominal symptoms at a single institution were randomly assigned to the EAC or TAC group. The mean number of adenomas per patient, adenoma detection rate, cecal intubation time, withdrawal time, mean number of adenomas per location, and adenoma size were compared. RESULTS: Overall, 800 patients were enrolled. The EAC and TAC groups comprised 372 and 393 patients, respectively. The groups did not significantly differ with respect to cecal intubation and withdrawal times. The mean number of adenomas per patient was significantly higher in the EAC group (1.13 vs 0.90, P = 0.04), particularly in the sigmoid colon (0.54 [201/372] vs 0.38 [149/393], P = 0.04). The adenoma detection rates were 48.1% and 45.0% in the EAC and TAC groups, respectively, albeit without significant difference between the two groups (P = 0.393). The total number of sessile-type adenomas (0.73 [270/372] vs 0.47 [183/393], P < 0.0001) and small polyps (≤ 5 mm) (0.53 [198/372] vs 0.41 [159/393], P = 0.016) was significantly higher in the EAC group. CONCLUSION: Endo-wing-assisted colonoscopy is significantly superior to TAC in terms of the mean number of adenomas per patient.

Safety and efficacy of the endoscopic delivery of capsule endoscopes in adult and pediatric patients: Multicenter Japanese study (AdvanCE-J study).

BACKGROUND AND AIM: We retrospectively determined the safety and efficacy of the endoscopic delivery (ED) of capsule endoscopes. METHODS: We enrolled 10,156 patients who underwent small bowel capsule endoscopy (SBCE), 3182 who underwent patency capsule (PC), and 1367 who underwent colon capsule endoscopy (CCE), at 11 gastroenterological and nine pediatric centers. RESULTS: Small bowel capsule endoscopies, PCs, and CCEs were endoscopically delivered to 546 (5.4%), 214 (6.7%), and 14 (1.0%) patients, respectively. Only mild complications occurred for 21.6% (167/774), including uneventful mucosal damage, bleeding, and abdominal pain. Successful ED of SBCE to the duodenum or jejunum occurred in 91.8% and 90.7% of patients aged <16 years and ≥16 years, respectively (P = 0.6661), but the total enteroscopy rate was higher in the first group (91.7%) than in the second (76.2%, P < 0.0001), for whom impossible ingestion (87.3%) was significantly more common than prolonged lodging in the stomach (64.2%, P = 0.0010). Successful PC and CCE delivery to the duodenum occurred in 84.1% and 28.6%, thereafter the patency confirmation rate and total colonoscopy rate was 100% and 61.5%, respectively. The height, weight, and age cutoff points in predicting spontaneous ingestion were 132 cm, 24.8 kg, and 9 years 2 months, respectively, in patients aged <16 years. Patients aged ≥16 years could not swallow the SBCEs mainly due to dysphagia (75.0%); those who retained it in the esophagus due to cardiac disease (28.6%), etc. and in the stomach due to diabetes mellitus (15.7%), etc. CONCLUSIONS: This large-scale study supports the safety and efficacy of ED in adult and pediatric patients. UMIN000042020.

A retrospective cohort study of factors influencing long procedure times in colorectal endoscopic submucosal dissection.

OBJECTIVE: To evaluate the outcomes and factors influencing colorectal endoscopic submucosal dissection (ESD) with a long procedure time. MATERIALS AND METHODS: In this single-center, retrospective study, we included 1,100 patients with 1,199 lesions who underwent colorectal ESD between April 2016 and December 2020. ESD was performed using an advanced system knife for lesions >20 mm. An S-O clip was used as the traction device. The long-time group (LP; procedure time >120 min) and normal-time group (NP; procedure time <120 min) were compared. RESULTS: The procedure times were 166.86 and 44.72 min in the LP and NP groups, respectively. The completion rate was higher in the NP group (96.5% vs. 83.5%, p = .001); the completed lesions were resected en bloc. Multivariate analysis revealed 18.8% and 7.8% of submucosal fibrosis in the LP and NP groups, respectively (odds ratio [OR] = 2.410, p = .026). Compared to the NP group, the LP group presented larger maximum lesion sizes and higher rates of R1 resection, and traction device use. Time to introduction of traction device use was longer in the LP than in the NP group (126.05 vs. 21.72 min; p < .001). Fibrosis tends to occur cecal lesions (OR 2.436, p = .011) and laterally spreading tumor-non-granular-pseudo-depressed (LST-NG-PD) (OR 2.6181, p = .001). CONCLUSIONS: Lesion size and fibrosis were factors associated with a long procedure time in colonic ESD. For fibrotic lesions (LST-NG-PD and cecal lesions), it is necessary to consider early use of traction devices and advisable to plan a strategy for the use of traction devices.

Detection of early stage gastric cancers in screening laser endoscopy using linked color imaging for patients with atrophic gastritis.

BACKGROUND AND AIMS: Laser endoscopy involves blue laser imaging in bright mode (BLI-bright). Linked color imaging (LCI) is superior to white light imaging (WLI) for detecting gastric cancers. This study aimed to detect gastric cancers on screening endoscopy using not only WLI but also BLI-bright and LCI in patients with atrophic gastritis. PATIENTS AND METHODS: A total of 500 patients with atrophic gastritis undergoing screening esophagogastroduodenoscopy were included. The gastric lumen was observed in the WLI mode, followed by the LCI and BLI-bright modes. When gastric neoplasms were suspected, the mode was changed to WLI, and we sprayed indigo carmine. Finally, biopsy specimens were taken for those lesions and pathological diagnosis was made. We compared the size, morphology, and color of gastric neoplasms found by the first WLI mode and those detected by only the LCI mode or BLI-bright mode. RESULTS: We detected 16 gastric neoplasms (3.2%), of which 13 were early gastric cancers (EGCs) and three were gastric adenomas. Ten EGCs and two gastric adenomas (75%) were detected by the first WLI mode; three EGCs and one gastric adenoma (25%) were missed by the first WLI mode and were detected by the LCI mode or BLI-bright mode. All were less than 1 cm in diameter and were reddish. Mean diameter of the lesions was significantly less for LCI-detected or BLI-bright-detected lesions than for WLI-detected lesions (7.8 vs 21.2 mm). CONCLUSIONS: Laser endoscopy is useful for detecting EGCs by LCI for patients with atrophic gastritis.

Linked color imaging versus white light imaging colonoscopy for colorectal adenoma detection: A randomized controlled trial.

BACKGROUND AND AIM: The adenoma detection rate is an important indicator of colonoscopy quality and colorectal cancer incidence. We compared the adenoma detection rates between white light imaging (WLI) and linked color imaging (LCI) colonoscopy. METHODS: Patients undergoing colonoscopy for positive fecal immunochemical tests, follow-up of colon polyps, and abdominal symptoms at three institutions were randomly assigned to the LCI or WLI groups. Mean adenoma number per patient (including based on endoscopists' experience), adenoma detection rate, cecal intubation time, withdrawal time, mean adenoma number per location, and adenoma size were compared. RESULTS: The LCI and WLI groups comprised 494 and 501 patients, respectively. No significant differences in the cecal intubation rate (LCI vs WLI: 99.5% vs 99.4%), cecal intubation time, and withdrawal time were noted between groups. The mean adenoma number per patient was significantly higher in the LCI group than in the WLI group (1.07 vs 0.88, P = 0.04), particularly in the descending [0.12 (58/494) vs 0.07 (35/501), P = 0.01] and sigmoid colon [0.41 (201/494) vs 0.30 (149/501), P ≤ 0.001]. However, the adenoma detection rate was 47.1% in the LCI group and 46.9% in the WLI group, with no significant difference (P = 0.93). The total number of sessile-type adenomas was significantly higher in the LCI group than in the WLI group (346/494 vs 278/501, P = 0.04). As for polyp size, small polyps (≤ 5 mm) were detected at a significantly higher rate in the LCI group (271/494 vs 336/501, P = 0.04). CONCLUSION: Linked color imaging is significantly superior to WLI in terms of mean adenoma number per patient.

Randomized control trial of adenoma detection rate in Endocuff-assisted colonoscopy versus transparent hood-assisted colonoscopy.

BACKGROUND AND AIM: Transparent hood-assisted colonoscopy (TAC) has been reported to improve the cecal insertion rate and adenoma detection rate (ADR). An endoscopic cap (Endocuff) with two rows of soft wings was recently developed to improve ADR, by flattening the mucosal folds during withdrawal. This randomized prospective control study aimed to compare ADR between Endocuff-assisted colonoscopy (EAC) and TAC. METHODS: A total of 513 patients undergoing colon adenoma screening were included. EAC was performed in 256 patients and TAC in 260 patients. Cecal intubation rate, cecal intubation time, ADR, and mean adenoma number per patient (MAP) were investigated in both groups (clinical trial registration: UMIN000016278). RESULTS: We excluded six patients in the EAC group and two patients in the TAC group because of colonic stenosis due to colonic adenocarcinomas. Finally, 250 patients (151 men/99 women, median age 62.1 years) were assigned to EAC and 258 patients (165 men/93 women, median age 64.3 years) were assigned to TAC. There were no significant differences in cecal intubation rate, intubation time, withdrawal time, and cleanliness score between groups. The ADR was 50.8% in EAC and 52.7% in TAC, with no significant difference (P = 0.666). The MAP was 1.35 in EAC and 1.20 in TAC, with no significant difference (P = 0.126). However, The MAP of diminutive adenomas (< 5 mm) tended to be higher in EAC than in TAC (P = 0.077). There was no significant difference in MAP in each segment between groups. CONCLUSIONS: Endocuff-assisted colonoscopy might be equivalent to TAC in cecal intubation time, ADR, and MAP.

Prevalence and Severity of Itching in Patients with End-Stage Renal Disease: Treatment with Nalfurafine Hydrochloride.

BACKGROUND/AIMS: In this study, we investigated the severity and frequency of uremic pruritus and itch-associated insomnia in patients with end-stage renal disease (ESRD) or chronic kidney disease (CKD). METHODS: This questionnaire-based study included outpatients with ESRD or CKD who were attending Tokorozawa Renal Clinic in Saitama Prefecture or Musashi Ranzan Hospital and were stable on treatment. The questionnaire was completed by patients on hemodialysis (HD) before a dialysis session and by patients on peritoneal dialysis (PD) or conservative treatment at the time of an outpatient hospital visit. RESULTS: Itching was reported by 61.6% of patients on HD, 61.5% on PD, and 43.2% on conservative CKD management. There was no statistically significant difference in the severity or frequency of itch according to whether patients were on HD for ESRD, PD for ESRD, or receiving conservative treatment for CKD. However, insomnia was significantly more common in the PD group than in the HD and conservative CKD groups. CONCLUSION: Better skin management is needed for itch in patients with ESRD or CKD. Moisturizing and lifestyle factors are important. Topical or oral medications may also be used. Nalfurafine, a κ receptor agonist, is now available in Japan for the treatment of uremic pruritus in these patients.

Eosinophil infiltration in the upper gastrointestinal tract of patients with bronchial asthma.

BACKGROUND: Eosinophilic esophagitis (EoE) is related to allergic diseases such as bronchial asthma (BA), atopic dermatitis, and allergic rhinitis. The aim of this study was to examine the eosinophil infiltration in the upper gastrointestinal (GI) tract in patients with BA using esophagogastroduodenoscopy. METHODS: Patients with BA who had upper GI tract symptoms were enrolled. Patients who received systemically administered steroids were excluded. Eosinophil infiltrations in the esophagus, stomach, and duodenum were examined with regard to the endoscopic findings and pathological findings of biopsy specimens (UMIN000010132). RESULTS: Ninety patients were enrolled from October in 2012 to September in 2014. Thirty-six were male, 54 were female, and the mean age was 57.5 years. Eighty-one (90%) used inhaled corticosteroids. Fourteen patients (15.6%) had reflux esophagitis, 8 of whom had grade A and 6 had grade B. No patient with EoE was observed. One female patient who had marked eosinophil infiltration in the esophagus, stomach, and duodenum was diagnosed as having eosinophilic gastroenteritis, but endoscopy showed only mucosal edema in the antrum. Another female patient who had marked eosinophil infiltration in the esophagus, stomach, and duodenum was diagnosed as having eosinophilic granulomatosis with polyangiitis, and endoscopy showed erosions in the antrum and the duodenum. Three patients had eosinophil infiltration in the stomach, but none of them had severe symptoms. CONCLUSIONS: Patients with asthma who had upper gastrointestinal symptoms rarely had eosinophilic gastrointestinal disorders. Biopsy specimens are of high importance in the diagnosis of eosinophilic gastrointestinal disorders even if there is no remarkable endoscopic finding.

Nintedanib-associated enterocolitis with intractable diarrhea: a case report.

Revised idiopathic pulmonary fibrosis treatment guidelines were published in 2015, and nintedanib was conditionally recommended. Although diarrhea is reported to be a common major adverse event associated with nintedanib, there have been few reports on detailed endoscopic findings of nintedanib-associated enterocolitis. A 74-year-old woman was diagnosed with idiopathic pulmonary fibrosis 4 years ago in May. She was started on nintedanib (300 mg). Three months later, hepatic dysfunction was observed; therefore, the drug was temporarily discontinued and then resumed at a dose reduction of 200 mg. Five months later, the patient developed diarrhea, and the dose was reduced to 150 mg. However, no effect was noted; hence, colonoscopy was performed. Various inflammatory lesions, such as erythema and erosions, were observed continuously at the rectum, which resembled ulcerative colitis. No improvement was observed 2 months after follow-up colonoscopy, and nintedanib-related enterocolitis was suspected. The dose was further reduced to 100 mg. Since the endoscopic findings of nintedanib-associated enterocolitis are similar to those of ulcerative colitis, it is critical to consider patients with diarrhea who are taking nintedanib as having associated enterocolitis and attempt to reduce or discontinue the drug if diarrhea does not improve with antidiarrheal agents.

Usefulness of a long hood for the detection of bleeding sites in colonic diverticular hemorrhage: A randomized controlled trial.

Background and Aim: The use of a hood at the tip of a colonoscope enables aspiration, inversion of the diverticulum, and observation of the inside of the diverticulum. In most previous studies, a short hood was used; however, observation of the diverticulum is often inadequate. Long food is promising by previous research, but it was a retrospective study using propensity matching and has some limitations. We compared the identification rate of stigmata of recent hemorrhage (SRH) between the long and standard hoods in cases of suspected colonic diverticular hemorrhage (CDH) to confirm the usefulness of long hood by prospective randomized controlled trial. Methods: Eighty patients (42 in the long hood group [L group] and 38 in the short hood group [S group]) who visited the Saitama Medical University Hospital and Tokai University Hachioji Hospital between December 2018 and July 2021 with a chief complaint of bloody stool and suspected CDH, based on the clinical course and imaging studies, were included. Patients were randomly assigned to the L or S group. Results: Regarding patient background, age was significantly higher in the L group; however, no significant differences were found in medical history or history of antithrombotic medication or nonsteroidal anti-inflammatory drug use. Identification rate of SRH was significantly higher in the L group (58.5%, 24/42 patients) than in the S group (26.3%, 10/38 patients) (P < 0.05). All patients were treated using the clip method, and the rate of rebleeding within 1 month was not significantly different between the two groups. Conclusion: A long hood was more useful compared with a short hood in identifying SRH of CDH (UMIN000034603).

The tumor suppressor microRNA-29c is downregulated and restored by celecoxib in human gastric cancer cells.

MicroRNAs (miRNAs) are small noncoding RNAs that function as endogenous silencers of target genes and play critical roles during carcinogenesis. The selective cyclooxygenase-2 (COX-2) inhibitor celecoxib has been highlighted as a potential drug for treatment of gastrointestinal tumors. The aim of this study was to investigate the role of miRNAs in gastric carcinogenesis and the feasibility of a new therapeutic approach for gastric cancer. miRNA expression profiles were examined in 53 gastric tumors including gastric adenomas (atypical epithelia), early gastric cancers and advanced gastric cancers and in gastric cancer cells treated with celecoxib. miRNA microarray analysis revealed that miR-29c was significantly downregulated in gastric cancer tissues relative to nontumor gastric mucosae. miR-29c was significantly activated by celecoxib in gastric cancer cells. Downregulation of miR-29c was associated with progression of gastric cancer and was more prominent in advanced gastric cancers than in gastric adenomas and early gastric cancer. In addition, expression of the oncogene Mcl-1, a target of miR-29c, was significantly increased in gastric cancer tissues relative to nontumor gastric mucosae. Activation of miR-29c by celecoxib induced suppression of Mcl-1 and apoptosis in gastric cancer cells. These results suggest that downregulation of the tumor suppressor miR-29c plays critical roles in the progression of gastric cancer. Selective COX-2 inhibitors may have clinical promise for the treatment of gastric cancer via restoration of miR-29c.

Applicability of second-generation colon capsule endoscope to ulcerative colitis: a clinical feasibility study.

BACKGROUND AND AIM: Colon capsule endoscopy has already been used for colon visualization and detection of polyps but its applicability to inflammatory bowel disease is still unconfirmed. The aim of this study was to assess the feasibility of evaluating the severity of mucosal inflammation in patients with ulcerative colitis (UC) using a second-generation colon capsule endoscope (CCE-2). METHODS: Forty patients with histological confirmed diagnosis of UC were enrolled. Low-volume (2 L) polyethylene glycol solution with prokinetics (mosapride citrate and metoclopramide) regimen was used for the bowel preparation. In Phase 1, consisting of 10 patients, to confirm appropriate CCE-2 bowel preparation for UC. In Phase 2, consisting of 30 patients, CCE-2 was performed with a fixed bowel preparation regimen. CCE-2 findings were recorded for 8 h starting from capsule ingestion and conventional colonoscopy was subsequently performed on the same day. CCE-2 procedure completion rate and the colon cleansing level with a 4-point grading scale (poor, fair, good, and excellent) were evaluated in Phase 2. Correlations between Matts endoscopic scores as judged by CCE-2 and conventional colonoscopy were calculated. RESULTS: CCE-2 procedure was completed within 8 h in 69% of the patients. The proportion of patients with good or excellent cleansing level was below 50%. However, Matts endoscopic scores determined by CCE-2 showed a strong correlation with scores obtained by conventional colonoscopy (average ρ = 0.797). CONCLUSIONS: Although modifications in bowel preparation are needed, CCE-2 might be feasible for assessing the severity of mucosal inflammation in patients with UC.

AdvanCE, a capsule endoscope delivery device, is effective in investigating a waterfall stomach.

AdvanCE is a useful device in patients who cannot swallow capsule endoscopes, or when these remain in the patient's stomach without passing into the duodenum. A net or snare may be used to guide the capsule endoscope into the duodenum when the capsule endoscope becomes stuck in the stomach, but it may be difficult to guide the capsule into the duodenum in some cases, particularly in those of waterfall stomach. In such cases, AdvanCE is found to be an effective guidance tool.