Comparison of etiological and physiological characteristics of fecal incontinence in men and women.

Fecal incontinence (FI) is often underreported and underestimated in men. Our aims were to clarify the causes and the physiological characteristics of FI in men and to underline the differences between etiological and physiological factors in men and women diagnosed with FI. The study cohort encompassed 200 men and 200 women who underwent anatomical and physiological evaluation for FI in a tertiary referral center specializing in pelvic floor disorders. All patients underwent endoanal ultrasound and anorectal manometry. Evacuation proctography was performed in some patients. Demographic, medical, anatomical, and physiological parameters were compared between the two study groups. Urge incontinence was the most frequent type of FI in both genders. In men, anal fistula, history of anal surgeries, rectal tumors, and pelvic radiotherapy were common etiologic factors, whereas history of pelvic surgeries was more common in women. Associated urinary incontinence was reported more frequently by women. External anal sphincter defects, usually anterior, were more common in women (M: 1.5%, F: 24%, P < 0.0001), whereas internal anal sphincter defect prevalence was similar in men and women (M: 6%, F: 12%, P = 0.19). Decreased resting and squeeze pressures were less common in men (M: 29%, F: 46%, P < 0.0001: M: 44%, F: 66%, P < 0.0001). The incidence of rectal hyposensitivity was higher in men (M: 11.1%, F: 2.8%, P < 0.0001), whereas rectal hypersensitivity was higher in women (M: 5.8%, F: 10.8%, P < 0.0001). Anorectal dyssynergia was more common in men (M: 66%, F: 37%, P < 0.0001). Significantly different etiological factors and physiological characteristics for FI were found in men. Acknowledging these differences is significant and may yield better treatment options.NEW & NOTEWORTHY Fecal incontinence (FI) in men has different etiological factors when compared with women. The prevalence of internal anal sphincter defect among men with FI was similar to women. Different manometric measurements were found among men with FI: decreased anal pressures were less common among men, whereas rectal hyposensitivity and anorectal dyssynergia were more common among men.

A Prospective, Single-Arm Study to Evaluate the Safety and Efficacy of an Autologous Blood Clot Product in the Treatment of Anal Fistula.

BACKGROUND: Surgical treatment of complex perianal fistula is technically challenging, associated with risk of failure, and may require multiple procedures. In recent years, several biologic agents have been developed for permanently eradicating anal fistulous disease with variable success. In this study, the treatment is an autologous whole-blood product created from the patients' blood. It forms a provisional matrix that was found to be safe and effective in healing acute and chronic cutaneous wounds. OBJECTIVE: The study aimed to assess the efficacy and safety of an autologous blood clot product as a treatment for transsphincteric perianal fistulas. DESIGN: A prospective single-arm study. SETTINGS: A single tertiary medical center. PATIENTS: Patients with simple or complex transsphincteric fistulas confirmed by MRI were included in the study. Cause was either cryptoglandular or Crohn's disease related (in the absence of active luminal bowel disease). INTERVENTION: The outpatient procedure was performed under general anesthesia and consisted of: 1) physical debridement and cleansing of the fistula tract; 2) suture closure of the internal opening; and 3) instillation of the autologous blood clot product into the entire tract. MAIN OUTCOME MEASURES: Safety and efficacy at 6- and 12-months after surgery. RESULTS: Fifty-three patients (77% men) with a median age of 42 (20-72) years were included in the study. Three patients withdrew consent, and 1 patient was lost to follow-up. At the time of this interim analysis, 49 and 33 patients completed the 6- and 12-month follow-up period. Thirty-four of the 49 patients achieved complete healing (69%) at 6 months, but 20 of the 33 patients (60%) achieved healing after 1 year. All patients who achieved healing at 6 months remained healed at the 1-year mark. In a subgroup analysis of patients with Crohn's disease, 7 of 9 patients completed 1-year follow-up, with 5 patients (71%) achieving clinical remission. No major side effects or postoperative complications were noted, but 2 adverse events occurred (admission for pain control and coronavirus 2019 infection). LIMITATIONS: Noncomparative single-arm pilot study. CONCLUSIONS: Treatment with an autologous blood clot product in perianal fistular disease was found to be feasible and safe, with an acceptable healing rate in both cryptoglandular and Crohn's disease fistula-in-ano. Further comparative assessment is required to determine its potential role in the treatment paradigm of fistula-in-ano. See Video Abstract . BRAZO PARA EVALUAR LA SEGURIDAD Y EFICACIA DE RDVER, UN COGULO DE SANGRE AUTLOGO, EN EL TRATAMIENTO DE LA FSTULA ANAL: ANTECEDENTES:El tratamiento quirúrgico de la fístula perianal compleja es técnicamente desafiante, se asocia con riesgo de fracaso y puede requerir múltiples procedimientos. En los últimos años, se han desarrollado varios agentes biológicos con el fin de erradicar permanentemente la enfermedad fistulosa anal con éxito variable. El tratamiento RD2-Ver.02 es un producto de sangre total autólogo creado a partir de la sangre de los pacientes, que forma una matriz provisional que resultó segura y eficaz para curar heridas cutáneas agudas y crónicas.OBJETIVO:Evaluar la eficacia y seguridad de RD2-Ver.02 como tratamiento para las fístulas perianales transesfinterianas.DISEÑO:Un estudio prospectivo de un solo brazo.LUGARES:Un único centro médico terciario.PACIENTES:Se incluyeron en el estudio pacientes con fístulas transesfinterianas simples o complejas confirmadas mediante resonancia magnética. La etiología fue criptoglandular o relacionada con la enfermedad de Crohn (en ausencia de enfermedad intestinal luminal activa).INTERVENCIÓN:El procedimiento ambulatorio se realizó bajo anestesia general y consistió en: 1) desbridamiento físico y limpieza del trayecto fistuloso; 2) cierre con sutura de la abertura interna; y 3) instilación de RD2-Ver.02 en todo el tracto.PRINCIPALES MEDIDAS DE VALORACIÓN:Seguridad y eficacia a los 6 y 12 meses después de la cirugía.RESULTADOS:Se incluyeron en el estudio 53 pacientes (77% varones) con una mediana de edad de 42 (20-72) años. Tres pacientes retiraron su consentimiento y un paciente se perdió durante el seguimiento. En el momento de este análisis intermedio, 49 y 33 pacientes completaron el período de seguimiento de 6 y 12 meses, respectivamente. Treinta y cuatro (34) pacientes lograron una curación completa (69%) a los 6 meses, mientras que 20 de 33 pacientes (60%) lograron una curación después de un año. Todos los pacientes que lograron la curación a los 6 meses permanecieron curados al año. En un análisis de subgrupos de pacientes con enfermedad de Crohn, 7/9 pacientes completaron un seguimiento de un año y 5 pacientes (71%) alcanzaron la remisión clínica. No se observaron efectos secundarios importantes ni complicaciones postoperatorias, mientras que ocurrieron 2 eventos adversos (ingreso para control del dolor e infección por COVID-19).LIMITACIONES:Estudio piloto no comparativo de un solo brazo.CONCLUSIONES:Se encontró que el tratamiento con RD2-Ver.02 en la enfermedad fístula perianal es factible y seguro, con una tasa de curación aceptable tanto en la fístula criptoglandular como en la de Crohn en el ano. Se requiere una evaluación comparativa adicional para determinar su papel potencial en el paradigma de tratamiento de la fístula anal. (Pre-proofed version ).

Validation of the Wexner scale in a Hebrew-speaking population.

INTRODUCTION: The Cleveland Clinic Incontinence Score, known as the Wexner Score (WS), is a simple, disease-specific questionnaire for anal incontinence (AI) assessment. We aimed to translate and validate a Hebrew version of the WS. METHODS: Between November 2018 and December 2019, the WS was back translated and reviewed by a multidisciplinary pelvic floor team. The questionnaire was filled out by patients visiting the urogynecology and surgical pelvic floor clinics. Two weeks after completion, the patients were contacted using telephone surveys to assess the test-retest reliability examination. Construct validity was assessed by comparing the WS to the Colorectal-Anal Distress Inventory 8 (CRADI-8), a part of the validated Hebrew version of the Pelvic Floor Distress Inventory questionnaire (PFDI-20). RESULTS: Overall, 91 female patients completed the WS questionnaire. Eighty-five percent (n = 78) responded to the re-test WS questionnaire. A high intraclass coefficient of 0.87 was found in the WS total score, with a range from 0.82 to 0.86 for its subscales. A significant positive relationship between the Hebrew versions of the WS and CRADI-8 scores was established (r = 0.66, p < 0.0001). CONCLUSION: A new, Hebrew-translated version of the WS is a reliable and valid instrument for assessing AI.

Prospective Observational Evaluation of Time-Dependency of Adalimumab Immunogenicity and Drug Concentrations: The POETIC Study.

OBJECTIVES: Adalimumab is usually self-injected at home, making prospective serial-sampling studies challenging and scarce. This has led to a gap in knowledge about evolution of anti-adalimumab antibodies (AAAs) over time and its correlation with clinical and inflammatory outcomes. METHODS: A program for home visits by physicians at induction, every 3 months and at event of relapse, was established prospectively for Crohn's disease (CD) patients. At each visit, patients' clinical scores were determined and sera were obtained for C-reactive protein, drug, and AAA levels. This cohort was compared to a parallel prospective cohort of infliximab-treated CD patients. In a subgroup of 29 patients, trough and in-between-trough levels were compared, to elucidate the importance of timing of sampling during the injection cycle. RESULTS: Ninety-eight CD patients starting adalimumab were prospectively followed (median follow-up 44 weeks) and 621 serum samples were analyzed. Thirty-three patients (32%) developed AAA; 18/33 (55%) of them as early as week 2, and 26/33 (79%) by week 14. Induction period AAAs were strongly associated with primary non-response (odds ratio (OR) = 5.4, 95% confidence interval (CI): 1.6-17.8, p = 0.005). As compared to antibodies-to-infliximab (ATI), AAA formation rate over time was significantly lower (p = 0.01) and AAA were much more specific-85% of AAA events were associated with loss-of-response compared with 58% rate for ATI (p = 0.01). In 29 patients sampled serially during an injection cycle, levels of drug and AAA seemed comparable between four time-points during a single cycle both in patients with or without AAA (n = 8, n = 21, respectively). CONCLUSIONS: When followed prospectively and serially, AAAs are found to arise earlier than previously appreciated and their impact may be more pronounced for primary rather than secondary, non-response. Drug and AAA levels were similar both at trough and in-between injections, enabling to simplify therapeutic drug monitoring of adalimumab.

Assessment of metagenomic Nanopore and Illumina sequencing for recovering whole genome sequences of chikungunya and dengue viruses directly from clinical samples.

BackgroundThe recent global emergence and re-emergence of arboviruses has caused significant human disease. Common vectors, symptoms and geographical distribution make differential diagnosis both important and challenging. AimTo investigate the feasibility of metagenomic sequencing for recovering whole genome sequences of chikungunya and dengue viruses from clinical samples.MethodsWe performed metagenomic sequencing using both the Illumina MiSeq and the portable Oxford Nanopore MinION on clinical samples which were real-time reverse transcription-PCR (qRT-PCR) positive for chikungunya (CHIKV) or dengue virus (DENV), two of the most important arboviruses. A total of 26 samples with a range of representative clinical Ct values were included in the study.ResultsDirect metagenomic sequencing of nucleic acid extracts from serum or plasma without viral enrichment allowed for virus identification, subtype determination and elucidated complete or near-complete genomes adequate for phylogenetic analysis. One PCR-positive CHIKV sample was also found to be coinfected with DENV. ConclusionsThis work demonstrates that metagenomic whole genome sequencing is feasible for the majority of CHIKV and DENV PCR-positive patient serum or plasma samples. Additionally, it explores the use of Nanopore metagenomic sequencing for DENV and CHIKV, which can likely be applied to other RNA viruses, highlighting the applicability of this approach to front-line public health and potential portable applications using the MinION.

The Severity of Symptoms Related to Irritable Bowel Syndrome is a Risk Factor for the Misclassification of Significant Organic Disease.

BACKGROUND AND AIMS: The diagnosis of irritable bowel syndrome (IBS) is based mainly on clinical evaluation. The reported incidence of misclassification of significant organic diseases in previously diagnosed IBS patients differs between studies. The aim of this study was to examine the incidence and risk factors for the misclassification of significant organic disease [colon cancer, inflammatory bowel disease (IBD), Celiac disease, and thyroid dysfunction] in a cohort of young patients with symptoms attributed to IBS. METHODS: In this population-based cohort study, we examined the incidence and risk factors for the diagnosis of a new significant organic diseases in a cohort of 2645 IBS patients. RESULTS: During follow-up, organic disease was diagnosed in 27 subjects (1.03%): IBD in 23, Celiac disease in 2, IBD and Celiac disease in 1, and hypothyroidism in1. The mean interval from the diagnosis of IBS to the diagnosis of an organic disorder was 13.08±8.51 months. Increased symptom severity was the only significant risk factor for the misclassification of an organic disease (hazard ratio, 2.26; 95% confidence interval, 1.01-5.05; P=0.047). The risk ratio for misclassification of organic diseases in moderate to severe IBS was increased by 2.575 (95% confidence interval, 1.10-6.51; P=0.027) as compared with mild IBS. CONCLUSIONS: The incidence of misclassification of major organic disease in IBS patients was low. Increased symptoms severity was the only significant risk factor for the misclassification of organic disorders. Further gastrointestinal evaluation should be considered in patients with moderate to severe symptoms attributed to IBS.

Feasibility of Bedside Bowel Ultrasound Performed by a Gastroenterologist for Detection and Follow-Up of Inflammatory Bowel Disease.

BACKGROUND: Bowel ultrasound has several possible uses in inflammatory bowel disease (IBD), including the initial evaluation of suspected IBD, monitoring of therapeutic response, detection of relapse, and diagnosis of complications as well as of extra-intestinal manifestations. However, its use has been limited mainly to countries where it is performed by the attending physician. OBJECTIVES: To investigate the feasibility and sensitivity of bedside bowel ultrasound performed by a gastroenterologist for assessing disease activity and complications in IBD. METHODS: We performed a feasibility study to compare the results of bowel ultrasound examination with those of another cross-sectional imaging modality (computed tomographic enterography or magnetic resonance enterography) in Crohn's disease, or with colonoscopy in ulcerative colitis. RESULTS: Between May 2015 and March 2016, 178 bowel ultrasound examinations were performed in 178 patients with suspected or established diagnosis of IBD. In 79 cases the results of another cross-sectional imaging or endoscopic examination performed within 3 months prior to the ultrasound exam were available. The sensitivity for detection of intestinal bowel thickening (a surrogate of inflammation) was 90%, and for detection of Crohn's disease complications, namely bowel stenosis and inflammatory mass, was 94% and 75%, respectively. CONCLUSIONS: Bowel ultrasound is a useful and feasible bedside imaging tool for the detection of inflammation and complications in IBD patients. Bedside bowel ultrasound can be a valuable non-invasive tool to assess disease activity and complications in IBD patients when performed by the attending physician.

Clinical Problem Solving: A Tobacco Merchant Who Can't Spit.

BACKGROUND: A 47 year old man presented with a combination of dry mouth and lightheadedness while standing. His medical background was unremarkable except for cigarette smoking and hyperlipidemia. Sjögren's syndrome was ruled out, and he was referred for evaluation of orthostatic hypotension, which by then included syncopal episodes and injuries. Additional symptoms included dry eyes, constipation, reduced sweating, and erectile dysfunction. After excluding medications and structural cardiac abnormalities as causes of orthostatic hypotension, a clinical autonomic evaluation was performed. The pattern of beat-to-beat blood pressure associated with performance of the Valsalva maneuver, and a low plasma norepinephrine level that did not increase in response to standing, established that the orthostatic hypotension was neurogenic. Treatment with an alpha-adrenoceptor agonist and fludrocortisone yielded partial improvement. After systemic diseases involving autonomic failure were excluded, cardiac sympathetic neuroimaging was performed by 123I-metaliodobenzylguanidine (MIBG) scanning. The normal uptake seen in the heart indicated intact post ganglionic sympathetic innervation. There were no signs of central neurodegeneration or peripheral neuropathy. Because of symptoms and signs of both parasympathetic and sympathetic failure without denervation, an autonomic ganglionopathy was considered. A high titer of antibody to the neuronal nicotinic receptor, which mediates ganglionic neurotransmission, was obtained. The diagnosis of autoimmune autonomic ganglionopathy (AAG) was made, and the management strategy shifted to first lowering the antibody burden by plasma exchanges and then instituting chronic anti-autoimmune treatment with rituximab and a low dose of cortiosteroid. The patient showed remarkable improvement.

[THE ISRAELI NEUROGASTROENTEROLOGY ASSOCIATION RECOMMENDATIONS FOR THE EVALUATION AND TREATMENT OF CHRONIC CONSTIPATION].

INTRODUCTION: This article summarizes the recommendations of the Israeli Neurogastroenterology and Motility Branch of the Israeli Gastroenterology Association for diagnosis and treatment of chronic constipation. It encompasses an overview of the definitions, the diagnostic approach and the possible treatment options in chronic constipation. This document is suitable for primary care physicians who are interested in understanding the major physiologic mechanisms for chronic constipation and the possible treatment options, as well as for the gastroenterology consultant who faces patients with tenacious chronic constipation.

Predictive factors for the diagnosis of irritable bowel syndrome in a large cohort of 440,822 young adults.

BACKGROUND: The prevalence of irritable bowel syndrome (IBS) in the community has been reported in numerous cross-sectional surveys. However, little is known about the incidence and predictive factors for the clinical diagnosis of IBS. METHODS: We examined the association of socioeconomic, anthropometric, and occupational factors with the incidence of IBS in a cohort of 440,822 young Israeli adults aged 18 to 39 who served in active military service during the years 2005 to 2011. RESULTS: During the follow-up of 1,925,003 person-years, IBS was diagnosed de novo in 976 patients, giving an incidence rate of 221:100,000 (0.2%) person-years for the diagnosis of IBS. On multivariable Cox analysis, higher socioeconomic status [hazard ratio (HR) 1.629; 95% confidence interval (CI), 1.328-1.999; P<0.0001], Israeli birth (HR 1.362; 95% CI, 1.084-1.712; P=0.008), Jewish ethnicity (HR 2.089; 95% CI, 1.344-3.248; P=0.001), education ≥than 11 years (HR 1.674; 95% CI, 1.019-2.751; P=0.042), and a noncombat military position (HR 1.196; 95% CI, 1.024-1.397; P=0.024) were found to be risk factors for the diagnosis or for the worsening of IBS. Overweight (HR 0.744; 95% CI, 0.589-0.941; P=0.014), obesity (HR 0.698; 95% CI, 0.510-0.95; P=0.025), living in a rural settlement (HR 0.705; 95% CI, 0.561-0.886; P=0.003), and Middle Eastern (HR 0.739; 95% CI, 0.617-0.884; P=0.001,) or North African and Ethiopian origin (HR 0.702; 95% CI, 0.585-0.842; P<0.001) were found to be protective for the diagnosis or the worsening of IBS. CONCLUSIONS: This study provides novel data on the socioeconomic, anthropometric, and occupational factors predictive for IBS development. The predictive factors for IBS diagnosis may point to the fact that stress had a lower impact on IBS incidence in our study cohort.

Comparison of dynamic transperineal ultrasound and defecography for the evaluation of pelvic floor disorders.

INTRODUCTION: X-ray defecography is considered the gold standard for imaging pelvic floor pathology. However, it is limited by the capability to demonstrate only the posterior pelvic compartment, significant radiation exposure, and inconvenience. Dynamic transperineal ultrasound (DTP-US) can visualize all of three pelvic floor compartments, is free of radiation, and does not cause significant discomfort. The aim of this study was to evaluate the level of consistency between defecography (DEF) and DTP-US in the diagnosis of pelvic floor deformations. METHODS: One hundred and five women (age 56 ± 11 years) suffering from constipation and fecal incontinence were clinically evaluated and further examined by DEF and DTP-US. The rate of diagnosis of pelvic floor hernias using the DTP-US was compared to that found on DEF. RESULTS: The specificity for the diagnosis of rectoceles was of 82% for mid-size rectocele and 98% for large rectoceles, and the sensitivity was of 59% for mid-size rectoceles and 50% for larger rectoceles. The sensitivity for the detection of intussusceptions, enteroceles, and rectal prolapse were 82, 74, and 75%, respectively. The specificity was 84% for the detection of intussusception, 92% for enteroceles, and 97% for the diagnosis of rectal prolapse. Higher rates of DTP-US diagnosis were obtained when the intussuscepted rectum moved closer toward the ultrasound probe. CONCLUSIONS: The sensitivity of DTP-US was good to excellent and the specificity was high. The added value of this technique in exploring all the compartments of the pelvic floor as well as the perineal muscles makes DTP-US a preferred procedure.

Current role of endoscopy in inflammatory bowel disease diagnosis and management.

PURPOSE OF REVIEW: This review will summarize the role of endoscopy in the diagnosis of inflammatory bowel disease (IBD), in assessing its activity, its management, interventional endoscopy, and cancer surveillance. RECENT FINDINGS: Endoscopy in IBD underwent major advances in the recent years, with the emergence of new techniques such as wireless video capsule endoscopy (WCE), device-assisted enteroscopy (DAE), chromoendoscopy, and confocal endomicroscopy. WCE is a minimally invasive tool, enabling the visualization of the entire small bowel mucosa. It has gained a substantial role in the evaluation of patients with suspected Crohn's disease and indeterminate colitis. With the correct use of the International Conference on Capsule Endoscopy criteria, WCE has a high positive predictive value in patients with suspected Crohn's disease. Moreover, WCE has a very high negative predictive value in patients with suspected Crohn's disease. DAE has established its role as a complementary tool in cases where there is need of biopsies or dilatation of strictures. Chromoendoscopy and confocal endomicroscopy are techniques that may assist in cancer surveillance in IBD patients. SUMMARY: Endoscopy has a major role in the diagnosis of IBD, assessing its extent, treating some of its complications, assessing the success of various treatments, and as a predictor of disease course.

Comparison of procedural sequence in same-day consecutive bidirectional endoscopy using moderate sedation: a prospective randomized study.

BACKGROUND: A sequential bidirectional endoscopy is commonly performed. However, the optimal sequence of procedures for same-day bidirectional endoscopy using moderate sedation has not been established. GOALS: The aim of this study was to characterize the optimal sequence of endoscopies for sequential bidirectional endoscopy. STUDY: This was a single-center, prospective, randomized study. A total of 163 patients aged 18 to 80 years, who were referred for bidirectional endoscopy for any indication, were randomized to start with upper or lower endoscopy. Initially, all patients received intravenously 50 mg of meperidine and 2.5 mg of midazolam. Patient's discomfort and satisfaction, as expressed by the amount of analgesia added to sustain conscious sedation, and the postprocedure satisfaction reported by the patients were set as primary outcomes. RESULTS: There was no significant difference in the total dose of midazolam added, patient's pain assessment and satisfaction from the anesthesia and the procedure, duration of endoscopies, or the time to cecal intubation between the esophagogastroduodenoscopy first and colonoscopy first groups. The rate of diagnosis of significant pathologies and the rate of procedures performed during the examinations were similar in both the study groups. Evaluation of patient's postprocedural recovery did not reveal significant differences. There was no significant variance between the performing physicians regarding anesthetic dosing, duration of examination, pain scoring, and the related patient's pain postprocedural assessment. CONCLUSIONS: There were no significant differences in the patient's discomfort and satisfaction, regardless of the procedural sequence.

Radiomics-Based Analysis of Intestinal Ultrasound Images for Inflammatory Bowel Disease: A Feasibility Study.

Background: The increasing adoption of intestinal ultrasound (IUS) for monitoring inflammatory bowel diseases (IBD) by IBD providers has uncovered new challenges regarding standardized image interpretation and limitations as a research tool. Artificial intelligence approaches can help address these challenges. We aim to determine the feasibility of radiomic analysis of IUS images and to determine if a radiomics-based classification model can accurately differentiate between normal and abnormal IUS images. We will also compare the radiomic-based model's performance to a convolutional neural network (CNN)-based classification model to understand which method is more effective for extracting meaningful information from IUS images. Methods: Retrospectively analyzing IUS images obtained during routine outpatient visits, we developed and tested radiomic-based and CNN-based models to distinguish between normal and abnormal images, with abnormal images defined as bowel wall thickness > 3 mm or bowel hyperemia with modified Limberg score ≥ 1 (both are surrogate markers for inflammation). Model performances were measured by area under the receiver operator curve (AUC). Results: For this feasibility study, 125 images (33% abnormal) were analyzed. A radiomic-based model using XG boost yielded the best classifier model with average test AUC 0.98%, 93.8% sensitivity, 93.8% specificity, and 93.7% accuracy. The CNN-based classification model yielded an average testing AUC of 0.75. Conclusions: Radiomic analysis of IUS images is feasible, and a radiomic-based classification model could accurately differentiate abnormal from normal images. Our findings establish methods to facilitate future radiomic-based IUS studies that can help standardize image interpretation and expand IUS research capabilities.

AI-luminating Artificial Intelligence in Inflammatory Bowel Diseases: A Narrative Review on the Role of AI in Endoscopy, Histology, and Imaging for IBD.

Endoscopy, histology, and cross-sectional imaging serve as fundamental pillars in the detection, monitoring, and prognostication of inflammatory bowel disease (IBD). However, interpretation of these studies often relies on subjective human judgment, which can lead to delays, intra- and interobserver variability, and potential diagnostic discrepancies. With the rising incidence of IBD globally coupled with the exponential digitization of these data, there is a growing demand for innovative approaches to streamline diagnosis and elevate clinical decision-making. In this context, artificial intelligence (AI) technologies emerge as a timely solution to address the evolving challenges in IBD. Early studies using deep learning and radiomics approaches for endoscopy, histology, and imaging in IBD have demonstrated promising results for using AI to detect, diagnose, characterize, phenotype, and prognosticate IBD. Nonetheless, the available literature has inherent limitations and knowledge gaps that need to be addressed before AI can transition into a mainstream clinical tool for IBD. To better understand the potential value of integrating AI in IBD, we review the available literature to summarize our current understanding and identify gaps in knowledge to inform future investigations.

Endoscopic assessment of the small bowel.

BACKGROUND: Small bowel imaging and endoscopy in IBD have undergone a tremendous change and advancement in the recent years. Modalities shifted from gastroscopy, colonoscopy and small bowel follow through to ileocolonoscopy, CT or MR enteroscopy, wireless video capsule endoscopy and balloon-assisted enteroscopy. METHODS: We reviewed the present role of endoscopy in assessing the small bowel in the context of IBD. RESULTS: Endoscopy has a major role in the diagnosis of IBD, in the assessment of its extent, treatment of complications, assessment of the success of various medications and as a predictor of disease course. Wireless capsule endoscopy (WCE) is a relatively new tool allowing direct, patient-friendly visualization of the entire small bowel mucosa. It has gained a substantial role in the evaluation of patients with suspected Crohn's disease (CD) and indeterminate colitis. WCE has a high positive predictive value in patients with suspected CD, when one uses more than two of the International Conference on Capsule Endoscopy criteria, and not less important a very high negative predictive value in patients with suspected CD. Its role in patients with known CD, in the assessment of their disease activity and extent, assessment of postsurgical small bowel recurrence and evaluation of mucosal healing is still unclear. Balloon-assisted enteroscopy has established its role as a complementary tool in cases where there is a need for biopsy or treatment (dilatation of strictures). CONCLUSIONS: The present review summarizes the role of endoscopy in the assessment of the small bowel in the context of IBD.

Prevalence and predictive factors for gastrointestinal pathology in young men evaluated for iron deficiency anemia.

BACKGROUND: The prevalence of gastrointestinal lesions in young men with iron deficiency anemia (IDA) is unknown, and there are no evidence-based recommendations for the evaluation of the gastrointestinal tract in this population. AIMS: The purpose of this study was to assess the prevalence of significant GI lesions among young males with IDA, and to shed light on potential predictors of their presence. METHODS: Clinical, endoscopic, and histological data was retrospectively collected from medical records of 347 young males with IDA. RESULTS: Clinically significant GI lesions were diagnosed in 62 %. Upper GI lesions were found in 35 %. Peptic disease was the most common finding, diagnosed in 30 %. Celiac disease was diagnosed in 4 %. Lower GI tract lesions were diagnosed in 34 %. The most common findings were hemorrhoids (17 %) and inflammatory bowel disease (16 %). Malignant lesions were not detected. GI lesions were encountered more frequently when respective symptoms were obtained. Multivariate analysis showed that the presence of GI symptoms and the use of proton pump inhibitors were associated with an increased likelihood of significant GI lesions. CONCLUSIONS: GI lesions are common among young men with IDA. GI evaluation is mandatory in symptomatic men and in asymptomatic men when the anemia is resistant to iron therapy. Symptoms may dictate the order of evaluation.

Combined 3D Endoanal Ultrasound and Transperineal Ultrasound Improves the Detection of Anal Sphincter Defects.

INTRODUCTION: Anal sphincter injury, mainly due to obstetric or iatrogenic etiology, is the most common cause of fecal incontinence (FI). Three-dimensional endoanal ultrasound (3D EAUS) is used for assessment of the integrity and the degree of anal muscle injury. However, 3D EAUS accuracy may be hampered by regional acoustic effects, such as intravaginal air. Therefore, our aim was to examine whether a combination of transperineal ultrasound (TPUS) and 3D EAUS would improve the accuracy of detection of anal sphincter injury. METHODS: We prospectively performed 3D EAUS followed by TPUS in every patient evaluated for FI in our clinic between January 2020 and January 2021. The diagnosis of anal muscle defects was assessed in each ultrasound technique by two experienced observers that were blinded to each other's assessments. Interobserver agreement for the results of the 3D EAUS and the TPUS exams was examined. A final diagnosis of anal sphincter defect was based on the results of both ultrasound methods. Discordant results were re-analyzed by the two ultrasonographers for a final consensus on the presence or absence of defects. RESULTS: A total of 108 patients underwent ultrasonographic assessment due to FI (mean age 69 ± 13). Interobserver agreement for the diagnosis of tear on EAUS and TPUS was high (83%) with Cohen's kappa of 0.62. EAUS confirmed anal muscle defects in 56 patients (52%), while TPUS confirmed them in 62 patients (57%). The final consensus agreed on the diagnosis of 63 (58%) muscular defects and 45 (42%) normal exams. The Cohen's kappa coefficient of agreement between the results of the 3D EAUS and the final consensus was 0.63. CONCLUSIONS: The combination of 3D EAUS and TPUS improved the detection of anal muscular defects. The application of both techniques for the assessment of the anal integrity should be considered in every patient going through ultrasonographic assessment for anal muscular injury.

Management of Chronic Anal Fissure with a Novel Topical Hemp-Herbal-Based Ointment: A Pilot Study.

Introduction: Anal fissure (AF) is a common anorectal disease. Although several pharmacological treatments are available, many patients still require surgical interventions. In this study, we aimed to evaluate the efficacy of an ointment based on a multifunctional blend of herbal ingredients including hemp (ProctoFiz) for chronic AF. Methods: A single-arm, questionnaire-based prospective study was conducted in a large tertiary center to evaluate the outcomes of patients suffering from chronic AF treated with topical ProctoFiz. Results: Ninety-two patients were included in the study, 54 (58.7%) were females with a median age of 39 (range 17-78). 32 patients (34.7%) suffered from recurrent AF before enrolling in the study, and 5 patients (5.4%) underwent previous surgical interventions for AF. Three patients (3.2%) were lost to follow-up, leaving 89 patients for analysis. Eighty patients (89.9%) reported significant improvement of symptoms after 1 week using ProctoFiz, and 79 patients reported continued improvement after 1 month of treatment. The mean pain Visual Analog Score (VAS) declined by 6.6 points (8.9 vs. 2.3; 95% CI: 7.20 to -5.99, p < 0.0001) following 1 week of treatment, with continuous improvement to a mean of 0.64 after 1 month. Negative impact on quality of life significantly decreased from a mean of 8.8 to 0.38 following a month of treatment (p < 0.0001), with significant reduction in the number of patients suffering from bleeding following bowel movements (64.1-2.5%; p = 0.0001). Conclusion: Hemp-based topical treatment of AF is feasible and significantly improves AF-correlated symptoms.

Laser hemorrhoidoplasty for II-IV grade hemorrhoids: should we treat them the same?

Laser Hemorrhoidoplasty (LHP) is a novel therapeutic option for hemorrhoids. In this study, we aimed to evaluate the post-operative outcomes of patients undergoing LHP surgery based on hemorrhoid grade. A retrospective analysis of a prospective database of all patients who underwent LHP surgery between September 2018 and October 2021 was performed. Patients' demographics, clinical perioperative data, and post-operative outcomes were recorded and analyzed. One hundred and sixty two patients that underwent laser hemorrhoidoplasty (LHP) were included. Median operative time was 18 min (range 8-38). Median total energy applied was 850 Joule (450-1242). Complete remission of symptoms following surgery was reported by 134 patients (82.7%), while 21 patients (13%) reported partial symptomatic relief. Nineteen patients (11.7%) presented with post-operative complications, and 11 patients (6.75%) were re-admitted following surgery. Post-operative complication rate was significantly higher in patients with grade 4 hemorrhoids compared to grades 3 or 2, due to a higher rate of post-operative bleeding (31.6% vs. 6.5% and 6.7%, respectively; p = 0.004). Furthermore, post-operative readmission rate (26.3% vs. 5.4% and 6.2%; p = 0.01) and reoperation rate were also significantly higher in grade IV hemorrhoids (21.1% vs. 2.2% and 0%; p = 0.001). Multivariate analysis found that grade IV hemorrhoids had a significantly higher risk for post-operative bleeding (OR 6.98, 95% CI 1.68-28.7; p = 0.006), 30-day readmission (OR 5.82, 95% CI 1.27-25.1; p = 0.018), and hemorrhoids recurrence (OR 11.4, 95% CI 1.18-116; p = 0.028). LHP is an effective treatment for hemorrhoids grades II-IV, but carries significant risk for bleeding and re-intervention in patients with grade IV hemorrhoids.