TOP 100 and detection of colorectal lesions in colon capsule endoscopy: more than meets the eye.

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

Identifying inflammatory bowel disease patients at risk of metabolic dysfunction-associated fatty liver disease: usefulness of non-invasive steatosis predictive scores.

BACKGROUND: Inflammatory bowel disease (IBD) patients have a higher risk of metabolic dysfunction-associated fatty liver disease (MAFLD) compared with the general population. However, it is not known whether available non-invasive hepatic steatosis scores are useful in predicting MAFLD in IBD patients. We aimed to analyze the performances of MAFLD screening score (MAFLD-S), Fatty Liver Index (FLI), Hepatic Steatosis Index (HSI) and Clinical Prediction Tool for NAFLD in Crohn's Disease (CPN-CD), in identifying MAFLD in IBD patients. METHODS: A cross-sectional study was carried out including consecutive adult IBD outpatients submitted to transient elastography (TE). MAFLD criteria were assessed, and hepatic steatosis (HS) was defined by a controlled attenuation parameter (CAP) >248 dB/m using TE. MAFLD-S, FLI, HSI, and CPN-CD were calculated and their accuracy for the prediction of MAFLD was evaluated through their areas under the receiver-operating characteristic (AUROC) curves. RESULTS: Of 168 patients, body mass index ≥25, type 2 diabetes mellitus, dyslipidemia and arterial hypertension were present in 76 (45.2%), 10 (6.0%), 53 (31.5%), 20 (11.9%), respectively. HS was identified in 77 (45.8%) patients, of which 65 (84.4%) fulfilled MAFLD criteria. MAFLD-S (AUROC, 0.929 [95% CI, 0.888-0.971]) had outstanding and FLI (AUROC, 0.882 [95% CI, 0.830-0.934]), HSI (AUROC, 0.803 [95% CI, 0.736-0.871]), and CPN-CD (AUROC, 0.822 [95% CI, 0.753-0.890) had excellent discrimination in predicting MAFLD. CONCLUSIONS: MAFLD-S, FLI, HSI and CPN-CD scores can accurately identify MAFLD in IBD patients, allowing the selection of those in whom hepatic steatosis and metabolic risk factors assessment may be particularly beneficial.

Bowel cleansing effectiveness and safety of 1L PEG + Asc in the real-world setting: Observational, retrospective, multicenter study of over 13000 patients.

Background and study aims Effective bowel cleansing is critical for detecting lesions during colonoscopy, highlighting the importance of bowel preparations. 1L polyethylene glycol (PEG) + ascorbate (Asc) is the only recommended 1L PEG product in Europe and the United States. Its efficacy was demonstrated in large-scale controlled trials and confirmed in smaller-scale real-world studies. However, no large-scale real-world data exist. Patients and methods This observational, retrospective, multicenter study, used outpatient follow-up data from medical records from 10 centers in Spain and two in Portugal. Outpatients aged ≥18 years using 1L PEG + Asc as bowel preparation were included. The main outcome measures were overall adequate colon cleansing (Boston Bowel Preparation Scale [BBPS] score ≥6 with BBPS score ≥2 in each segment) and high-quality cleansing of the right colon (BBPS score=3). Results Data from 13169 eligible patients were included. Overall cleansing success was achieved in 89.3% (95%CI 88.7%-89.8%) and high-quality cleansing in the right colon in 49.3% (95%CI 48.4%-50.2%) of patients. For the overnight split-dose and same-day regimens, overall adequate quality cleansing success rate was 94.7% and 86.7% ( P <0.0001) and high-quality cleansing of the right colon rate was 65.4% and 41.4% ( P <0.0001), respectively. Colonoscopy was completed in 97.3% of patients, with non-completion due to poor preparation in only 0.8%; 2.3% of patients experienced at least one adverse event (AE). Conclusions This large-scale, real-world study demonstrates the effectiveness of 1L PEG + Asc in the total and right colon, with a low percentage of patients with AEs in routine clinical practice.

Reply to comment on "Ultrasonographic scores for ileal Crohn's disease assessment: better, worse or the same as contrast­enhanced ultrasound?

We read the comments by Nylund K et al. regarding our paper "Ultrasonographic scores for ileal Crohn's disease assessment: Better, worse or the same as contrast­enhanced ultrasound?". Intestinal ultrasound has become one of the most valuable developments in the past decade, a non-invasive, well-tolerated exam, with an easy repeatability, and absence of sedation, ionizing radiation, or preparation. Particularly for inflammatory bowel disease, where there is a lack of agreement of patient's symptoms with disease activity, in an era where the paradigm of mucosal healing is changing to transmural healing, and with the emergence of several therapies leading to repeated imaging surveillance, it is essential to highlight the role of intestinal ultrasound. Although intestinal ultrasound is an increasingly used tool to monitor inflammatory bowel disease activity, there is no widely accepted reproducible activity index, since the methodology for the development of the scores was shown to be insufficient in most studies and none have been adequately validated (Bots et al., J Crohns Colitis 12:920-9, 2018). In our study, we showed that the contrast-enhanced ultrasound (CEUS) peak enhancement derived from the time-intensity curve (TIC) is a promising non-invasive emerging method with a good accuracy to correlate clinical and endoscopic activity in the terminal ileum, superior to intestinal ultrasound scores relying on bowel wall thickness and colour Doppler.

Small Bowel CLEansing Assessment and Report (SB-CLEAR): Standardizing bowel preparation report in capsule endoscopy.

BACKGROUND AND AIM: Small-bowel (SB) cleansing is crucial to assess the reliability of capsule endoscopy (CE) findings. However, the presence of multiple grading systems is hampering their use in clinical practice. In 2020, Colon CLeansing Assessment and Report (CC-CLEAR) was created and validated. We sought to develop and validate a new score for the evaluation of the SB cleansing, adapted from CC-CLEAR, aiming to standardize CE reporting regarding the quality of preparation. METHODS: The new grading score, SB CLeansing Assessment and Report (SB-CLEAR), divided the SB into three tertiles, each being scored depending on the percentage of visualized mucosa (0, < 50%; 1, 50%-75%; 2, > 75%; 3, > 90%). The overall classification was a sum of each segment score, graded between excellent, good, and inadequate (0-5). Any segment scoring ≤1 resulted in inadequate overall classification. CE videos were prospectively evaluated by two experienced CE readers blinded to each other. RESULTS: We included 52 CEs, 41(78.8%) female, with a mean age of 57.9 ± 17.9 years. Inter-observer agreement was very strong for each tertile (first: r = 0.863; second: r = 0.865; third: r = 0.861; P < 0.001), which resulted in overall excellent correlation when considering the quality of preparation in all tertiles (r = 0.940; P < 0.001). By applying final classifications of "inadequate," "good," and "excellent," correlation between observers was also very strong (r = 0.875; P < 0.001). CONCLUSIONS: SB-CLEAR is an innovative and reproducible grading score for evaluation of SB preparation quality in CE, with overall excellent inter-observer agreement. Along with CC-CLEAR, this may become a valuable tool to uniformize reporting of bowel preparation quality in CE.

Stepping it up: Physical activity is associated with a lower incidence of prolonged gastric transit time in capsule endoscopy.

BACKGROUND AND AIM: Physical activity has been proposed as a potential factor influencing capsule endoscopy (CE) gastric transit time (GTT). However, there is no reported factual evidence confirming this association. We aimed to prospectively assess the effect of physical activity in the first hour of CE in the occurrence of prolonged GTT. METHODS: This is a prospective study including consecutive patients undergoing CE. For each patient, a step counter was attached to the CE register. The number of steps during the first hour of the procedure was registered. The main outcome was prolonged GTT (CE remaining in the stomach for > 1 h). Outcomes were adjusted for possible confounders by multivariate analysis. RESULTS: We included 100 patients, 60% undergoing small bowel CE and 40% colon CE. The mean number of steps in the first hour was significantly lower in patients with prolonged GTT (2009 ± 1578 steps) comparatively with those without prolonged GTT (3597 ± 1889 steps) (P < 0.001). On multivariate analysis including significant confounders, steps in the first hour were an independent predictor of prolonged GTT (P = 0.018). Single-handedly, the number of steps taken in the first hour had a good acuity for predicting prolonged GTT (area under the curve = 0.74; P < 0.001), with an optimal cut-off of 2000 steps (sensitivity 81.3% and specificity 70%). CONCLUSIONS: Physical activity during the first hour of CE significantly decreased the occurrence of prolonged GTT. These findings pave the way for further definition of clear instructions to give to patients undergoing CE.

Finding Predictors of Azathioprine-Induced Pancreatitis in Patients With Inflammatory Bowel Disease.

OBJECTIVES: Azathioprine (AZA)-induced pancreatitis (AIP) is a common, idiosyncratic adverse effect whose incidence and risk factors data in inflammatory bowel disease (IBD) patients are not fully clarified. We aimed to establish the incidence, clinical course and identify risk factors for AIP. METHODS: A retrospective study including all IBD patients on AZA between January 2013 and July 2020 was conducted. Patients with AIP were considered. RESULTS: Azathioprine-induced pancreatitis occurred in 33 patients (7.5%; 442 patients on AZA). The mean time receiving AZA until AIP was 25 days, with a mean dose of 88 mg. All patients had a mild course of disease, which resolved with suspension of AZA and with no complications. Smoking (P = 0.02), single daily dose of AZA (P < 0.001), and concomitant budesonide (P = 0.001) were risk factors for AIP. In multivariate analysis, concomitant treatment with budesonide (odds ratio, 5.3; P = 0.002) and single daily dose of AZA (odds ratio, 3.8; P = 0.002) were the only predictors of AIP. CONCLUSIONS: Although AIP was a relatively common adverse effect, it presented a mild course in all patients. Smoking, concomitant use of budesonide, and single-dose regimen of AZA should be avoided in IBD patients treated with AZA.

Direct oral anticoagulants are associated with potentially bleeding lesions in suspected mid-gastrointestinal bleeding.

BACKGROUND AND AIM: Direct oral anticoagulants (DOACs) became a widespread alternative in anticoagulant therapy. Nevertheless, concerns are raised about their safety, with increased gastrointestinal bleeding rates being described. There are scarce studies regarding DOACs effect on small-bowel capsule endoscopy (SBCE) findings. We aimed to assess if the detection of lesions with high bleeding potential on SBCE was significantly different in patients treated with DOACs when compared to non-anticoagulated patients and to patients anticoagulated with other agents. METHODS: Cohort study including consecutive patients who underwent SBCE for suspected mid-gastrointestinal bleeding (MGIB) in 2019 and 2020. RESULTS: From 148 patients, 38 (25.7%) were anticoagulated, of which 26 (68.4%) with DOACs. P2 lesions were detected in 36.5% (n = 54) of the patients. These lesions were more frequently detected in patients under DOACs treatment when compared to non-anticoagulated patients (69.2% vs. 29.1%; p=.001), and also when compared to patients treated with other anticoagulants (69.2% vs. 33.3%; p=.037). No differences in P2 lesions detection were observed between patients treated with other anticoagulants and non-anticoagulated patients (33.3% vs. 29.1%; p=.747). In multivariate analysis, DOACs usage was significantly associated with higher detection rates of P2 lesions on SBCE, when adjusted for classical risk factors for MGIB (OR: 3.38; 95%CI = 1.23-9.26; p=.018). CONCLUSIONS: Despite their undeniable cardiovascular benefits and easy applicability, DOACs should still be considered with caution. These drugs were significantly associated with higher risk of potentially bleeding lesions on SBCE when compared to other anticoagulants and represent an independent risk factor for MGIB when adjusted for other variables.

Bowel cleansing efficacy for colonoscopy: prospective, randomized comparative study of same-day dosing with 1-L and 2-L PEG + ascorbate.

Background and study aims Polyethylene glycol (PEG) bowel preparations are effective but associated with high ingestion volume. In this study, 1-L PEG and 2-L PEG preparations were compared in a randomized, colonoscopist-blinded, single-center trial. Patients and methods Patients were aged > 18 years, required colonoscopy, and provided informed consent. Randomization was 1:1 to 1-L PEG or 2-L PEG, based on hospital identification number (odd or even). Preparations were administered using same-day dosing adjusted for colonoscopy start time. The primary endpoint was successful bowel preparation on the Boston Bowel Preparation Scale (BBPS) (no segment scored < 2). Results A total of 852 patients were randomized. In the intention-to-treat (ITT) population, significantly more patients had diabetes in the 2-L PEG arm, resulting in the creation of the modified-ITT population (mITT) that excluded diabetic patients to correct the imbalance (1-L PEG, n = 239; 2-L PEG, n = 238). In the mITT, there was no significant difference in successful cleansing between 1-L PEG and 2-L PEG (88.3 % vs. 82.4 %; P  = 0.067). Excellent cleansing (BBPS 7-9; no segment < 2) was significantly improved with 1-L PEG (60.7 % vs. 50.4 %; P  < 0.024), as were mean scores in the right and left colon (right: 2.47 vs. 2.30; P  < 0.008; left: 2.55 vs. 2.39; P  = 0.008). Adverse events were mild to moderate in intensity and none resulted in discontinuation. Rates of nausea and vomiting were significantly higher with 1-L PEG, but that did not affect successful cleansing. Conclusions The lower-volume 1-L PEG was associated with higher levels of excellent bowel cleansing and greater mean segmental scores on the BBPS than 2-L PEG.

US-FLI score - Is it possible to predict the steatosis grade with an ultrasonographic score?

OBJECTIVES: A recent ultrasonographic score (Ultrasonographic fatty liver indicator (US-FLI)) allows to grade steatosis severity on ultrasound (US).We aimed to evaluate the agreement of US-FLI with the controlled attenuation parameter (CAP) in patients with non-alcoholic fatty liver disease (NAFLD). METHODS: Initially, inter-observer agreement for the score was assessed between 3 physicians using a sample of 31 patients.Later, 96 patients with NAFLD were included and several anthropometric/clinical/analytical parameters were assessed and US and transient elastography was performed. RESULTS: Physicians showed an excellent absolute agreement regarding the total score, with an average Interclass Correlation Coefficient of 0.972(95% CI 0.949-0.986). Comparing US-FLI with CAP, considering the previously defined cut-off for steatosis >S1(268dB/m) and > S2(280dB/m), US-FLI had a good discriminative capacity for both grades, with areas under the curve (AUC) of 0.88(p < 0.001) and 0.90(p < 0.001), respectively.Also, US-FLI ≤ 3 points had a negative predictive value of 100% for steatosis >S2 and US-FLI ≥6 points had a positive predictive value (PPV) of 94.0% for steatosis >S2. When comparing the clinical score Fatty Liver Index (FLI) for the same CAP cut-offs, it showed a weak discriminative capacity for both grades, with AUC of 0.65(p = 0.030) and 0.66(p = 0.017). AUC for US-FLI and FLI were significantly different for both cut-offs (p < 0.001). CONCLUSION: US-FLI has an excellent reproducibility and a good discriminative capacity for the different steatosis grades.Scores ≤3points exclude significant steatosis and scores ≥6 points have a PPV of 94,0% for steatosis >S2.US-FLI was significantly superior to the clinical score FLI in the discrimination between steatosis grades.

Small-bowel transit time in capsule endoscopy: a determinant factor for the diagnosis of small-bowel bleeding.

BACKGROUND: small-bowel capsule endoscopy (SBCE) is the gold standard for the study of small-bowel bleeding (SBB). Recent studies suggest that longer small-bowel transit times (SBTT) may be associated with a higher diagnostic yield of SBCE. AIM: the aim of the study was to investigate if longer SBTT is a predictive factor of positive findings on SBCE in a population that underwent SBCE for suspected SBB. METHODS: a retrospective single-center study including consecutive SBCEs between May 2012 and May 2019, due to suspected SBB. A positive SBCE was considered in the presence of lesions with high bleeding potential such as ulcers, angioectasias, and tumors (P2 lesions, according to the Saurin classification). RESULTS: we included 372 patients, 65.9 % female, with a median age of 67 (IQR: 19-97) years. We observed that patients with P2 lesions (n = 131; 35.2 %) in SBCE exhibited a longer SBTT (p = 0.01), were older (p < 0.001), were more frequently male (p = 0.019), and suffered more frequently from arterial blood hypertension (p = 0.011), diabetes (p = 0.042), chronic kidney disease (p = 0.003), and heart failure (p = 0.001). In the logistic analysis, significant predictive factors for the presence of P2 lesions included age (OR: 1.027; 95 % CI: 1.009-1.045; p = 0.004), SBTT (OR: 1.002; 95 % CI: 1.001-1.005; p = 0.029), and male gender (OR: 1.588; 95 % CI: 1.001-2.534; p = 0.049). CONCLUSIONS: patients with longer SBTT had higher rates of lesions with high bleeding potential (P2). SBTT along with previously well-defined factors such as age and male gender were the only independent predictive factors for the presence of P2 lesions. These findings may suggest that a slower passage of the capsule through the small bowel may allow a better diagnostic yield for significant lesions.

Colon Capsule CLEansing Assessment and Report (CC-CLEAR): a new approach for evaluation of the quality of bowel preparation in capsule colonoscopy.

BACKGROUND AND AIMS: Current colon capsule (CC) cleansing grading scales rely on subjective parameters and lack proper interobserver agreement. We should strive for higher intra- and interobserver agreement for the evaluation of the cleansing quality of CCs. Here we sought to validate a new grading scale for the evaluation of CC cleansing. METHODS: For the new grading scale, named Colon Capsule CLEansing Assessment and Report (CC-CLEAR), the colon was divided in 3 segments: right-sided, transverse, and left-sided colon. Each segment was scored according to an estimation of the percentage of visualized mucosa (0, <50%; 1, 50%-75%; 2, >75%; 3, >90%). The overall cleansing classification was a sum of each segment score, grading between excellent (8-9), good (6-7), and inadequate (0-5). Any segment scoring ≤1 resulted in inadequate overall classification. Videos were reviewed and scored using CC-CLEAR and the Leighton-Rex grading scale by 2 experienced operators blinded to each other. Kendall's coefficient evaluated inter- and intraobserver agreement. RESULTS: We included 58 consecutive CCs, corresponding to 75.9% women, with a mean age of 65 years. Overall cleansing CC-CLEAR classifications were as follows: reader A, 22.4% (n = 13) excellent, 31% (n = 18) good, and 46.5% (n = 27) inadequate; and reader B, 24.1% (n = 14) excellent, 22.4% (n = 13) good, and 53.4% (n = 31) inadequate. CC-CLEAR interobserver agreement was superior to the Leighton-Rex scale (Kendall's W .911 vs .806, respectively; P < .01). The intraobserver agreement for CC-CLEAR was excellent for both readers (P > .01). CONCLUSIONS: CC-CLEAR is a new practical and reliable grading scale for the evaluation of bowel preparation quality using a CC, with excellent inter- and intraobserver agreement.

Small Bowel Angioectasias Rebleeding and the Identification of Higher Risk Patients.

BACKGROUND: Small bowel capsule endoscopy (SBCE) is the gold standard for suspected small bowel bleeding (SBB). Angioectasias are the most common vascular anomalies in the gastrointestinal tract and have been reported as the source of SBB in up to 80% of patients. Considering their frequency, their usual intermittent bleeding nature, and their risk of rebleeding, the aim of this study was to identify some features and possible predictors of rebleeding in the presence of these lesions. METHODS: This is a retrospective study, which included consecutive SBCE with angioectasias between April 2008 and December 2017 with a minimum follow-up of 12 months. Rebleeding was defined as a drop of hemoglobin ≥ 2 g/dl and/or in the presence of hematochezia or melenas with negative esophagogastroduodenoscopy and ileocolonoscopy. Data were collected from medical records, and angioectasias were classified by number, location, size, and type. Univariate and multivariable statistical analysis was performed to identify possible predictors of rebleeding. RESULTS: From a total of 630 patients submitted to SBCE for suspected SBB, 129 with angioectasias were included; 59.7% were female, with a median age of 72 (19-91) years old and a mean follow-up of 44.0 ± 31.9 months. In 32.6% (n = 42) of the patients, at least one episode of rebleeding was documented. The presence of heart failure (OR 3.41; IC95% 1.18-9.89; p = 0.024), the size of the angioectasias (OR 5.41; IC95% 2.15-13.6; p < 0.001), and smoking status (OR 3.15; IC95% 1.07-9.27; p = 0.038) were independent predictor factors of rebleeding. CONCLUSION: Heart failure, smoking status, and angioectasias with a size superior to 5 mm are independent predictor factors of rebleeding in a population with angioectasias diagnosed by SBCE.

P051 Identifying High-Risk Patients With Acute Severe Ulcerative Colitis: Is the ACE Index Useful?

BACKGROUND: Treatment delay in patients admitted with acute severe ulcerative colitis (ASUC) are associated with increased mortality. Therefore, it is essential to identify on admission patients at high-risk of steroid nonresponse who may benefit from earlier second-line treatment or surgical intervention. Recently, the ACE index was developed and includes 3 variables at admission: C-reactive protein (CRP) ≥50mg/dL, albumin ≤30g/L and endoscopic severity (Mayo endoscopic score=3), and ranges between 0-3 points. An index of 3 has been shown to be useful to identify patients with acute ulcerative colitis with high-risk of steroid nonresponse. OBJECTIVES: To assess the ACE index performance in predicting steroids response in ASUC. METHODS: Retrospective study including consecutive admissions for ASUC according to Truelove and Witts definition between January 2005 and December 2020. The ACE index was calculated and its accuracy for predicting response to steroids on admission in ASUC was assessed through the area under the curve (AUC). RESULTS: Sixty-five patients were included of whom 78.5% responded to steroids. Mean CRP (p = 0.01), albumin (p=0.02) and endoscopic severity score (p < 0.001) at admission were significantly different between responders and nonresponders, as opposed to Ulcerative Colitis Endoscopic Index of Severity (UCEIS) score (p = 0.32). Median ACE index was 2. The ACE index was a predictor of steroids response (AUC 0.789; p = 0.001); 50.0% of patients with an index of 3 did not respond to steroids, and 86.3% of patients with an index inferior to 3 responded to steroids (positive predictive value 50.0%; negative predictive value of 86.3%). CONCLUSION: The ACE index is an accurate predictor of steroids response on admission in ASUC. However, in our study, the ACE index doesn´t discriminate whose high-risk patients would benefit from earlier therapeutic escalation, since only 50.0% of patients with an index of 3 did not respond to steroids.

Combination therapy in inflammatory bowel disease patients: do we need to maximize the dose of azathioprine?

BACKGROUND: The use of combination therapy of anti-TNFα and thiopurines in inflammatory bowel disease (IBD) is associated with greater efficacy and lower immunogenicity. However, the dose of thiopurine in this setting remains to be elucidated. AIM: To compare the trough levels, anti-TNFα antibodies and the inflammatory biomarkers between three groups in combotherapy: group 1 (dose of azathioprine <1 mg/kg); group 2 (dose of azathioprine ≥1 and <2 mg/kg), and group 3 (dose of azathioprine ≥2 mg/kg). METHODS: A retrospective study was performed, selecting all patients with established diagnosis of IBD who were on combined maintenance treatment. RESULTS: We included 99 patients, 52.5% female with median age 33 (17-61) years. Eighty patients (80.8%) were diagnosed with Crohn's disease and 19 (19.2%) with ulcerative colitis. Seventy-one (71.8%) patients were on infliximab (IFX) and 28 (28.3%) were on adalimumab (ADA). In patients treated with IFX, there were no differences in trough levels (p=.976) or formation of antibodies anti-IFX (p=.478) between groups. Moreover, there were no differences in inflammatory biomarkers: CRP (p=.385) and fecal calprotectin (p=.576) among the three groups. Regarding patients treated with ADA, there were no differences in trough levels of ADA (p=.249), formation of antibodies anti-ADA (p=.706) or in inflammatory biomarkers: CRP (p=.738) and fecal calprotectin (p=.269) among the three groups. CONCLUSION: In our cohort, there were no differences between anti-TNFα trough levels, formation of anti-TNFα antibodies or inflammatory biomarkers among patients in combotherapy with azathioprine, irrespective of its dosage. In conclusion, our study suggests that maintaining therapeutic levels of anti-TNFα drugs without antibodies formation is feasible with lower doses of azathioprine, minimizing its side effects.

Simplify to improve in capsule endoscopy - TOP 100 is a swift and reliable evaluation tool for the small bowel inflammatory activity in Crohn's disease.

Background: Capsule endoscopy is a widely recognized method to study the small bowel, including in patients with Crohn's disease (CD). The Lewis score (LS) is a valuable tool in this setting, able to assess inflammatory activity. TOP100, a new software tool of the RAPID Reader®, emerged to assist in the time-consuming capsule reading process, by automatically selecting 100 images that will most likely contain abnormalities.Aim: Evaluate the agreement between TOP100 and classic reading (CR) in determining LS in the setting of CD.Methods: Retrospective study including consecutive patients undergoing small bowel capsule endoscopy (SBCE) for suspected or established CD. One experienced reader performed CR and calculated the LS. Another experienced reader, blinded to the CR results, reviewed all SBCE videos using TOP100 and calculated the LS.Results: One hundred and fifteen patients were included. SBCE detected significant inflammatory activity (LS ≥135) in 64 patients (55.7%). We verified a strong agreement between the two methods of capsule reading (Kappa = 0.83, p < .001), with an agreement on 89.6% of the cases. The agreement was superior in moderate-to-severe inflammatory activity (Kappa = 0.92, p < .001). All cases of moderate-to-severe activity detected by CR were identified by TOP100 as significant inflammatory activity. A good agreement was verified in all tertiles (p < .001).Conclusions: Although the classical review of the entire video remains the gold standard, the TOP100 has been shown to be a useful tool in assisting the reader in a prompt calculation of LS, in particular for identifying patients with moderate-to-severe inflammatory disease.

Esophagogastroduodenoscopy Findings in Patients on the Waiting List for Bariatric Surgery.

BACKGROUND: Bariatric surgery (BS) is one of the most effective approaches to weight loss. Performing esophagogastroduodenoscopy (EGD) prior to BS is controversial but allows the detection and treatment of mucosal lesions that may affect surgical decision and type of surgery. AIM: The aim of this study was to identify the frequency of gastric lesions and Helicobacter pylori (Hp) infection in a group of asymptomatic patients on the waiting list for BS. METHODS: This is a retrospective descriptive study including patients undergoing EGD before BS. RESULTS: A total of 360 patients were included with a mean age of 42.1 ± 10.8 years, 319 (88.6%) were females, with a mean body mass index of 42.8 ± 5.44 kg/m2. Regarding endoscopic findings, 25.6% presented no endoscopic lesions, 61.6% presented hyperemic gastropathy, 11.4% erosive gastropathy, 1.1% gastric polyp, and 0.3% gastric ulcer. Histologically, no changes were observed in 20.8% of the patients, 239 (66.4%) presented with superficial gastritis, 11.7% (n = 42) had chronic atrophic gastritis and intestinal metaplasia (n = 34 in the antrum, n = 1 in the body, and n = 7 in both the antrum and the body), and 1.7% (n = 6) had low-grade dysplasia. Hp was positive in 251 (69.7%) patients. We found that patients with metaplasia or dysplasia were more frequently submitted to surgical techniques that did not exclude the stomach (55.8 vs. 16.4%, p < 0.001). CONCLUSION: EGD with histological analysis plays an important role in the pre-surgical evaluation in BS, with a high rate of pathological findings in asymptomatic patients. These findings may have an impact on the long-term management and outcomes of these patients.

Primary colon mantle lymphoma: a misleading macroscopic appearance

Mantle cell lymphoma (MCL) of the colon is a rare entity, usually presenting as lymphomatous polyposis. We report the case of a 43-year-old male with an unusual colonic MCL in the form of a single exophytic and ulcerous lesion with necrotic areas associated with an ileo-cecal intussusception. The endoscopic appearance suggested adenocarcinoma. However, the diagnosis was made by histology and immunohistochemistry studies of the endoscopic biopsies

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CECDAIic - a new useful tool in pan-intestinal evaluation of Crohn's disease patients in the era of mucosal healing.

Background: Pan-intestinal capsule endoscopy (Pan-CE) has been used to assess both the small and large bowel inflammation in Crohn's disease (CD) patients in a single examination. The capsule endoscopy Crohn's disease activity index (CECDAI) was initially developed to measure mucosal disease activity in the small bowel, although in 2018, it was extended to the colon for standardization of inflammatory activity (CECDAIic). The aim of this study was to apply the CECDAIic in a cohort of CD patients that underwent Pan-CE to evaluate the inter-observer agreement and the correlation between this score and inflammatory parameters.Methods: The videos were read and scored using the CECDAIic by three independent experienced operators, blinded to the results of the standard workup. Statistical analysis was performed with SPSS®, using Kendall's coefficient to evaluate the inter-observer agreement. Spearman correlation (rs) was used to access the correlation between the score and inflammatory biomarkers.Results: Included 22 patients, 59.1% males with mean age of 30.7 ± 11.1 years. The median CECDAIic score was 9.17 (0-37). The overall CECDAIic score Kendall coefficient was 0.94, demonstrating a statistically significant (p < .001) and excellent agreement between the three observers. In addition, we found a very good correlation between CECDAIic and calprotectin (rs = 0.82; p = .012) and a moderate correlation with C-reactive protein (CRP, rs = 0.50; p = .019).Conclusions: CECDAIic is a new score with excellent inter-observer agreement and strong correlation with calprotectin levels.

Primary colon mantle lymphoma: a misleading macroscopic appearance!

Mantle cell lymphoma (MCL) of the colon is a rare entity, usually presenting as lymphomatous polyposis. We report the case of a 43-year-old male with an unusual colonic MCL in the form of a single exophytic and ulcerous lesion with necrotic areas associated with an ileo-cecal intussusception. The endoscopic appearance suggested adenocarcinoma. However, the diagnosis was made by histology and immunohistochemistry studies of the endoscopic biopsies.