An unpredictable gastrointestinal bleed

A 65-year-old male complained of persistent melena for 6 days, and displayed anemia symptoms without hematemesis, vomiting, and abdominal distention. He was diagnosed as ruptured aneurysm of aortic sinus Valsalva, and had received coronary artery occlusion 1 month ago. After the operation, he was continually prescribed clopidogrel 75 mg once daily. The laboratory examination showed blood hemoglobin concentration was 60 g/L without other conspicuous abnormality. Unfortunately, neither esophagogastroduodenoscopy (EGD) nor colonoscopy found no obvious bleeding lesions. And abdominal computed tomography angiography (CTA) and enhanced computed tomography (CT) showed no obvious abnormal findings. Moreover, capsule endoscopy revealed small intestinal with mucosal erosion (Figure 1A). After discontinued clopidogrel, blood transfusion, and support therapy, his symptoms was resolved with negative fecal occult blood, continued clopidogrel 75 mg once daily, and uneventfully discharged 1 week later. (AU)

“Clip coupled with an elastic ring” internal traction for endoscopic submucosal dissection of a rectal neuroendocrine tumor: a junior endoscopist experience

A 64-year-old female was found a rectal neuroendocrine tumor (NET) for cancer screening examination. Endoscopic ultrasonography (EUS) revealed a hypoechoic lesion (8.3*6.6 mm) originating from the submucosa layer. “Clip coupled with elastic ring” internal traction for endoscopic submucosal dissection (ESD) was used to remove the NET according to the procedure removal of a duodenal tumor1. The procedures are following: 1. Marking around the lesion with a margin of approximately 5 mm. 2. Submucosal injection and circumference incision around the lesion. 3. Applied clip coupled with elastic ring internal traction. 4. Submucosal injection. 5.Precise dissection was performed with the NET being en bloc resection. 5. Closed the mucosal defect. Finally, the Histopathology confirmed a neuroendocrine tumor. (AU)

Endoscopic submucosal dissection coupled with "modified clip coupled with elastic ring" traction removing rectal neuroendocrine tumor.

A 50-year-old female complained of discomfort of lower abdomen, and a colonoscopy revealed a rectal neuroendocrine tumor (NET). Endoscopic ultrasonography (EUS) showed a hypoechoic lesion (8.5*7.6 mm) originating from the submucosa layer. Endoscopic submucosal dissection (ESD) coupled with "modified clip coupled with elastic ring" traction was performed to remove the NET. Following procedures previously described, we made a subtle change.

A submucosal lesion of the rectum: an unexpected MALT.

A 57-year-old female was found a 12 mm × 10 mm submucosal lesion in the rectum with a smooth mucosa and telangiectasia The lesion was considered as a neuroendocrine tumor, and removed by endoscopic submucosal dissection (ESD) It was finally diagnosed with mucosa-associated lymphoid tissue (MALT) lymphoma with negative margin by pathological examination and histopathological test. MALT lymphoma in the rectum is rare and difficult to diagnose without histopathological test. In this case, the characteristic of this case is telangiectasia on the surface of lesion. Therefore, our findings suggested small lesion in rectum but big in impact.

Exploring the efficacy of herbal medicinal products as oral therapy for inflammatory bowel disease.

Inflammatory bowel disease (IBD) encompasses a collection of idiopathic diseases characterized by chronic inflammation in the gastrointestinal (GI) tract. Patients diagnosed with IBD often experience necessitate long-term pharmacological interventions. Among the multitude of administration routes available for treating IBD, oral administration has gained significant popularity owing to its convenience and widespread utilization. In recent years, there has been extensive evaluation of the efficacy of orally administered herbal medicinal products and their extracts as a means of treating IBD. Consequently, substantial evidence has emerged, supporting their effectiveness in IBD treatment. This review aimed to provide a comprehensive summary of recent studies evaluating the effects of herbal medicinal products in the treatment of IBD. We delved into the regulatory role of these products in modulating immunity and maintaining the integrity of the intestinal epithelial barrier. Additionally, we examined their impact on antioxidant activity, anti-inflammatory properties, and the modulation of intestinal flora. By exploring these aspects, we aimed to emphasize the significant advantages associated with the use of oral herbal medicinal products in the treatment of IBD. Of particular note, this review introduced the concept of herbal plant-derived exosome-like nanoparticles (PDENs) as the active ingredient in herbal medicinal products for the treatment of IBD. The inclusion of PDENs offers distinct advantages, including enhanced tissue penetration and improved physical and chemical stability. These unique attributes not only demonstrate the potential of PDENs but also pave the way for the modernization of herbal medicinal products in IBD treatment.

Stem cell-derived intestinal organoids: a novel modality for IBD.

The organoids represent one of the greatest revolutions in the biomedical field in the past decade. This three-dimensional (3D) micro-organ cultured in vitro has a structure highly similar to that of the tissue and organ. Using the regeneration ability of stem cells, a 3D organ-like structure called intestinal organoids is established, which can mimic the characteristics of real intestinal organs, including morphology, function, and personalized response to specific stimuli. Here, we discuss current stem cell-based organ-like 3D intestinal models, including understanding the molecular pathophysiology, high-throughput screening drugs, drug efficacy testing, toxicological evaluation, and organ-based regeneration of inflammatory bowel disease (IBD). We summarize the advances and limitations of the state-of-the-art reconstruction platforms for intestinal organoids. The challenges, advantages, and prospects of intestinal organs as an in vitro model system for precision medicine are also discussed. Key applications of stem cell-derived intestinal organoids. Intestinal organoids can be used to model infectious diseases, develop new treatments, drug screens, precision medicine, and regenerative medicine.

Ligation-assisted endoscopic resection to remove a small esophageal lesion (< 20 mm) originating from muscularis propria.

A 35-year-old female complained of slight dysphagia for 3 months. Her physical examination and laboratory tests were unremarkable. Esophagogastroduodenoscopy (EGD) revealed a submucosal tumor (SMT) in the lower esophagus. Then, endoscopic ultrasonography (EUS) revealed that a hypoechoic echo lesion (10mm*12mm) originated from muscularis propria. Subsequently, ligation-assisted endoscopic resection was performed to remove the esophageal lesion. The steps were briefly described as follows: Marking dots in the SMT, and injecting submucosally beneath the marking dots. Incising apical mucosal surface around the marking dots Assembling an endoloop and ligation device (MAJ-339; Olympus). Ligating the SMT with endoloop. Cold snare the SMT.Ligating the defect using another endoloop. Histopathology confirmed a leiomyoma). After 2 months follow-up, EGD revealed healing of the esophageal lesion.

An unpredictable gastrointestinal bleeding.

A 65-year-old male complained of persistent melena for 6 days, and displayed anemia symptoms without hematemesis, vomiting, and abdominal distention. He was diagnosed as ruptured aneurysm of aortic sinus Valsalva, and had received coronary artery occlusion 1 month ago. After the operation, he was continually prescribed clopidogrel 75 mg once daily. The laboratory examination showed blood hemoglobin concentration was 60 g/L without other conspicuous abnormality. Unfortunately, neither esophagogastroduodenoscopy (EGD) nor colonoscopy found no obvious bleeding lesions. And abdominal computed tomography angiography (CTA) and enhanced computed tomography (CT) showed no obvious abnormal findings. Moreover, capsule endoscopy revealed small intestinal with mucosal erosion (Figure 1A). After discontinued clopidogrel, blood transfusion, and support therapy, his symptoms was resolved with negative fecal occult blood, continued clopidogrel 75 mg once daily, and uneventfully discharged 1 week later.

"Clip coupled with elastic ring" internal traction for endoscopic submucosal dissection of a rectal neuroendocrine tumor: a junior endoscopist experience.

A 64-year-old female was found a rectal neuroendocrine tumor (NET) for cancer screening examination. Endoscopic ultrasonography (EUS) revealed a hypoechoic lesion (8.3*6.6 mm) originating from the submucosa layer. "Clip coupled with elastic ring" internal traction for endoscopic submucosal dissection (ESD) was used to remove the NET according to the procedure removal of a duodenal tumor1. The procedures are following: 1. Marking around the lesion with a margin of approximately 5 mm. 2. Submucosal injection and circumference incision around the lesion. 3. Applied clip coupled with elastic ring internal traction. 4. Submucosal injection. 5.Precise dissection was performed with the NET being en bloc resection. 5. Closed the mucosal defect. Finally, the Histopathology confirmed a neuroendocrine tumor.

An unexpected gastric cardia submucosal lesion.

An esophagogastroduodenoscopy revealed a submucosal lesion in the gastric cardia of a 55-year-old man.Endoscopic ultrasonography showed a hypoechoic echo lesion originated from the muscularis propria layer considering a leiomyoma or stromal tumor.a submucosal tunneling endoscopic resection was successfully performed to remove the lesion and the diagnosis is hepatoid adenocarcinoma.This is the first report on a case of gastric HAC originated from submucous layer.

Nursing Cooperation Pattern for Patients With Advanced Pancreatic Cancer and Abdominal Pain Undergoing Endoscopic Ultrasound-guided Celiac Plexus Neurolysis.

Context: Patients with pancreatic cancer (PC) at a late stage often suffer from severe abdominal pain due to the invasion of celiac plexus, and the analgesics they receive often have intolerable side effects. Endoscopic, ultrasound-guided, celiac plexus neurolysis (EUS-guided CPN) can have a good therapeutic effect. Objective: The study intended to evaluate the ability of two nursing cooperation patterns to reduce patients' pain, decrease operation times, increase operational efficiency, and increase nurses' satisfaction, for patients with advanced PC and abdominal pain who received EUS-guided CPN. Design: The research team designed a retrospective controlled study. Setting: The study took place at the Shenzhen People's Hospital of the Second Clinical Medical College of Jinan University in Shenzhen, China, and at the Changhai Hospital of the Second Military Medical University in Shanghai, China. Participants: Participants were 40 patients with advanced PC who received EUS-guided CPN at one of the two hospitals between January 2019 and January 2020. Intervention: Twenty participants at Changhai Hospital received the traditional nursing cooperation pattern and became the control group, and 20 participants at the Shenzhen People's Hospital received the new nursing cooperation pattern and became the intervention group. Outcome Measures: The study measured clinical data, nursing measures, diagnostic significance, and key points for the two patterns as well as compared the effects of the new nursing cooperation method to that of traditional nursing. If the measurement data met the requirements for normality, the team used the two independent sample t-test for the intergroup comparisons. If normality wasn't satisfied, the team used medians and interquartile ranges (IQRs) for expression and the rank sum test for the intergroup comparisons. Counting data were expressed using the constituent ratio, and team used the chi-square test for comparisons between groups. P < .05 was considered to be statistically significant. Results: The operations were successful, and no complications occurred. No significant difference existed in the pain scores between the control group and the intervention group (P > .05), while a significant difference occurred in the nurses' operation times and satisfaction. Not only were the scores for operation times for the control group (97) and the intervention group (59) significantly different, but also the nurses' satisfaction was significantly higher for the intervention group postintervention, at 83.35 ± 5.25, than for the control group, at 62.25 ± 8.18 (P < .001). Such a new nursing cooperation method could assist in patient's rehabilitation and increase nurses' satisfaction. Conclusions: The new nursing cooperation method for patients with advanced PC and abdominal pain undergoing EUS-guided CPN can reduce operation time and improve nurses' satisfaction.

Extracellular Vesicles: The Next Generation Theranostic Nanomedicine for Inflammatory Bowel Disease.

The recent rapid development in the field of extracellular vesicles (EVs) based nanotechnology has provided unprecedented opportunities for nanomedicine platforms. As natural nanocarriers, EVs such as exosomes, exosome-like nanoparticles and outer membrane vesicles (OMVs), have unique structure/composition/morphology characteristics, and show excellent physical and chemical/biochemical properties, making them a new generation of theranostic nanomedicine. Here, we reviewed the characteristics of EVs from the perspective of their formation and biological function in inflammatory bowel disease (IBD). Moreover, EVs can crucially participate in the interaction and communication of intestinal epithelial cells (IECs)-immune cells-gut microbiota to regulate immune response, intestinal inflammation and intestinal homeostasis. Interestingly, based on current representative examples in the field of exosomes and exosome-like nanoparticles for IBD treatment, it is shown that plant, milk, and cells-derived exosomes and exosome-like nanoparticles can exert a therapeutic effect through their components, such as proteins, nucleic acid, and lipids. Moreover, several drug loading methods and target modification of exosomes are used to improve their therapeutic capability. We also discussed the application of exosomes and exosome-like nanoparticles in the treatment of IBD. In this review, we aim to better and more clearly clarify the underlying mechanisms of the EVs in the pathogenesis of IBD, and provide directions of exosomes and exosome-like nanoparticles mediated for IBD treatment.

Impact of an Abdominal Compression Bandage on the Completion of Colonoscopy for Obese Adults: A Prospective Randomized Controlled Trial.

Methods: Eligible patients were randomly allocated into the abdominal bandage and conventional groups during a routine colonoscopy. The primary outcome was CCR. Results: A total of 250 eligible patients were randomly assigned to the abdominal bandage and conventional groups from January 2021 to April 2021. Eleven patients (five in the abdominal bandage group and six in the conventional group) were excluded due to schedule cancellation after randomization, and 239 patients were eventually included in the final analysis. There were no significant differences between the two groups regarding baseline characteristics (P > 0.05). Furthermore, no significant differences were observed in terms of advanced adenoma detection rate (AADR), polyp detection rate (PDR), bowel preparation scale (BBPS), bubble scale (BS), and withdrawal time between the two groups (P > 0.05). However, compared with the conventional group, the cecal insertion time (CIT) of the abdominal bandage group was significantly shortened (279.00 (234.50-305.75) vs. 421.00 (327.00-485.00), P < 0.001), and the CCR (96.7% vs. 88.2%, P = 0.01) and adenoma detection rate (ADR) (47.5% vs. 32.8%, P < 0.001) were improved. Besides, logistic regression analysis showed that body mass index (BMI) and abdominal compression bandage were associated with CCR. Conclusions: Abdominal compression bandages could effectively shorten CIT and improve CCR and ADR for obese patients during a routine colonoscopy. This trial is registered with the Chinese Clinical Trial Registry (No. ChiCTR2100043556).

The Feasibility and Safety of the Clip-and-Snare Method with a Prelooping Technique for Gastric Submucosal Tumors Removal: A Single-Center Experience (with Video).

Aim: This study compared the efficacy and safety of endoscopic submucosal dissection (ESD) combined with clip-and-snare method and a prelooping technique (CSM-PLT) with ESD alone for the treatment of gastric submucosal tumors (gSMTs). Methods: We retrospectively enrolled a matched group of 86 patients who received ESD combined with CSM-PLT or ESD alone from July 2010 to July 2020. The primary outcomes included complete resection, en bloc resection, and R0 resection. Results: Eighty-six patients with gSMTs were enrolled in ESD combined with CSM-PLT group and ESD group, respectively. There were no significant differences in gender, age, tumor size, tumor location, and tumor origin between the two groups. The complete resection, en bloc resection, and R0 resection rates were comparable between two groups (P=1, P=0.31, and P=0.25, respectively). There were no significant differences in terms of hospital stays, hospitalization cost, postoperative complications, and residual rate (P=0.42, P=0.74, P=0.65, and P=1, respectively) between the two groups. However, the ESD combined with CSM-PLT was associated with a shorter procedure duration and fewer intraoperative complications (P < 0.001 and P=0.024, respectively). In addition, the incidence of intraoperative bleeding in ESD combined with CSM-PLT group was significantly lower than that in ESD group (P=0.04). Conclusion: Both ESD combined with CSM-PLT and ESD were effective and safe modalities for the treatment of gSMTs. However, ESD combined with CSM-PLT was associated with a shorter procedure duration and fewer intraoperative complications.

Endoscopic resection in combination with ligation for the treatment of duodenal subepithelial lesions: a single-center experience

Introduction and aim: duodenal subepithelial lesions (SELs) are increasingly detected during endoscopic examinations. However, no feasible and safe methods are available to remove duodenal SELs. The present study aimed to assess the feasibility and safety of endoscopic resection in combination with ligation (ER-L) for the removal of duodenal SELs.Patients and methods: a total of 101 patients with duodenal SELs underwent ER-L from February 2010 to February 2020. The primary outcomes were complete resection, en bloc resection and R0 resection. The secondary outcomes included procedure duration, bleeding, perforation and residual lesions. A total of 101 patients with 101 duodenal SELs (ranged from 8.4 mm to 20.2 mm in size) were included in the study.Results: most of the SELs (95.1 %) originated from the submucosal layer and were successfully removed using ER-L. The rates of complete resection, en bloc resection and R0 resection were 100 %, 96.0 % and 88.1 %, respectively. The median procedure duration was eight minutes. There were no severe complications, except for four patients who developed post-procedure bleeding (4.0 %) and recovered after conservative treatment. Furthermore, no residual lesions were detected during the follow-up period (median of 36 months). In fact, logistic regression analysis showed that the size of duodenal SELs was an independent factor for R0 resection during the ER-L procedure.Conclusion: in conclusion, ER-L is feasible and safe to remove duodenal SELs that originate from the submucosal layer and are less than 20 mm. However, the feasibility and safety of the ER-L should be further confirmed when removing the duodenal SELs that originate from the muscularis propria (MP) layer and are larger than 20 mm in diameter. (AU)

Comparison of Two Different Accesses Single Orifice Percutaneous Endoscopic Surgery in Diagnosis of Ascites of Unknown Origin: A Retrospective Study.

Background: Ascites is a common clinical finding caused by many different diseases, so we developed a technique termed single orifice percutaneous endoscopic surgery (SOPES) which can access peritoneal cavity through the contralateral McBurney's point or umbilicus to seek the underlying causes. In this study, we describe the initial clinical experience of SOPES and compare the application of two accesses. Methods: This is a retrospective study performed between 2007 and 2018. Patients with ascites of unknown origin who underwent these two kinds of SOPES were included. Main outcomes were measured by diagnostic accuracy, complication rate, procedure time, time till stitches removal, length of hospital stay, and hospital cost. Results: 148 patients successfully undergone SOPES via the contralateral McBurney's point (IM group, n = 70) or the umbilicus (UM group, n = 78). 63 patients in the IM group and 71 patients in the UM group reached clear diagnosis (90.0% vs. 91.0%, p = 0.831). The overall complication rate was 5.4%, while the UM group was higher than the IM group (10.3% vs. 0%, p = 0.017). All complications were resolved after medical treatment, and no mortality resulted from this procedure. The procedure time and the time until stitches removal in the UM group were longer than that in the IM group. There were no significant differences in length of hospital stay and hospital cost between the two groups. Conclusions: SOPES, which combines the strength of minimally invasive single orifice incision and flexible angles of examination and instrumentation, is a newly developed flexible endoscopic surgical modality that provides new important clinical valuable in evaluation of ascites of unknown origin. Moreover, SOPES via the contralateral McBurney's point was safer than the umbilicus approach.