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Using a systematic literature search of original articles published during 2023 in Gastrointestinal Endoscopy (GIE) and other high-impact medical and gastroenterology journals, the GIE Editorial Board of the American Society for Gastrointestinal Endoscopy compiled a list of the top 10 most significant topic areas in general and advanced GI endoscopy during the year. Each GIE Editorial Board member was directed to consider 3 criteria in generating candidate topics—significance, novelty, and impact on global clinical practice—and subject matter consensus was facilitated by the Chair through electronic voting and a meeting of the entire GIE Editorial Board. The 10 identified areas collectively represent advances in the following endoscopic spheres: GI bleeding, endohepatology, endoscopic palliation, artificial intelligence and polyp detection, artificial intelligence beyond the colon, better polypectomy and EMR, how to make endoscopy units greener, high-quality upper endoscopy, endoscopic tissue apposition and closure devices, and endoscopic submucosal dissection. Each board member was assigned a topic area around which to summarize relevant important articles, thereby generating this overview of the "top 10" endoscopic advances of 2023. [ABSTRACT FROM AUTHOR]

Purpose of review: Chronic breathlessness is a troublesome symptom experienced by people with advanced malignant and nonmalignant disease. Disease-directed therapies are often insufficient in the management of chronic breathlessness. Therefore, pharmacological and nonpharmacological breathlessness-specific interventions should be considered for select patients. Recent findings: There is some evidence to support the use of low-dose opioids (≤30 mg morphine equivalents per day) for the relief of breathlessness in the short term. However, additional studies are needed to understand the efficacy of opioids for chronic breathlessness in the long term. Nonopioid therapies, including inspiratory muscle training, fan-to-face therapy, l -menthol and inhaled nebulized furosemide show some promise for the relief of breathlessness in advanced disease. There is insufficient evidence to support the use of anxiolytics and benzodiazepines and cannabis for chronic breathlessness. Summary: More research is needed to identify therapies for the management of chronic breathlessness. [ABSTRACT FROM AUTHOR]

Purpose of review: Exertional breathlessness is common and pervasive across various chronic disease populations. To accurately assess response to intervention and optimize clinical (symptom) management, detailed assessment of exertional breathlessness is imperative. This review provides an update on current approaches to assess exertional breathlessness and presents the need for individualized assessment of breathlessness standardized for the level of exertion. Recent findings: Breathlessness assessment tools commonly invite people to recall their breathlessness while at rest with reference to activities of daily living. To directly quantify breathlessness, however, requires assessment of the dimensions of breathlessness (e.g., sensory intensity, quality, and unpleasantness) in response to a standardized exercise stimulus. Different exercise stimuli (e.g., self-paced, incremental, and constant work rate exercise tests) have been used to elicit a breathlessness response. Self-paced (e.g., 6-min walk test) and incremental exercise tests assess exercise tolerance or endurance, and are not recommended for assessment of exertional breathlessness. Constant work rate tests, however, including recently validated 3-min constant-rate stair stepping and walking tests, standardize the exercise stimulus to enable the breathlessness response to be directly quantified and monitored over time. Summary: To adequately guide symptom management and assess intervention efficacy, clinicians and researchers should assess breathlessness with multidimensional assessment tools in response to a standardized and individualized exercise stimulus. [ABSTRACT FROM AUTHOR]

Purpose of review Breathlessness is a common and distressing symptom in patients with chronic obstructive pulmonary disease (COPD) and fibrotic interstitial lung disease (ILD), particularly during exercise. Effective medical management of exertional breathlessness in people living with COPD and fibrotic ILD is challenging for healthcare providers and requires an understanding of its mechanisms. Thus, in this brief review we summarize recent advances in our understanding of the pathophysiological mechanisms of exertional breathlessness in COPD and fibrotic ILD. Recent findings The collective results of recent physiological and clinical trials suggest that higher intensity ratings of exertional breathlessness in both COPD and fibrotic ILD compared to healthy control individuals is mechanistically linked to the awareness of greater neural respiratory drive (quantified using inspiratory muscle electromyography) needed to compensate for pathophysiological abnormalities in respiratory mechanics and pulmonary gas exchange efficiency. Summary Any therapeutic intervention capable of decreasing intrinsic mechanical loading of the respiratory system and/or increasing pulmonary gas exchange efficiency has the potential to decrease the prevalence and severity of activity-related breathlessness and improve related clinical and patient-reported outcomes (e.g., exercise tolerance and health-related quality of life) by decreasing neural respiratory drive in people with COPD and fibrotic ILD. [ABSTRACT FROM AUTHOR]

Nonvariceal upper gastrointestinal (UGI) hemorrhage remains a significant health and economic burden. As the use of urgent endoscopy for UGI hemorrhage has increased, there has been a decline in associated mortality. Endoscopic hemostasis is based on risk stratification of stigmata of recent hemorrhage. A Doppler endoscopic probe can provide further risk stratification by detecting arterial blood flow under the lesion and as a guide to successful endoscopic treatment. Standard treatment options for endoscopic hemostasis include submucosal injection therapy usually in combination with either thermal coagulation or through-the-scope clips. A large over-the-scope clip, which has been used to close fistulas and perforations, has been shown to be effective in cases of refractory nonvariceal UGI hemorrhage, and might also be useful in other types of gastrointestinal bleeding. [ABSTRACT FROM AUTHOR]

Background and Aims Few prospective reports describe the short-term natural history of colon diverticular hemorrhage based on stigmata of recent hemorrhage, and none include blood flow detection for risk stratification or as a guide to definitive hemostasis. Our purposes were to report the 30-day natural history of definitive diverticular hemorrhage based on stigmata and to describe Doppler probe blood flow detection as a guide to definitive hemostasis. Methods Different cohorts of patients with severe diverticular bleeding and stigmata on urgent colonoscopy are reported. For 30-day natural history, patients were treated medically. If severe rebleeding occurred, they had surgical or angiographic treatment. We report natural history with major stigmata (active bleeding, visible vessel, or adherent clot) and no stigmata or flat spots after clots were washed away. We also report Doppler probe detection of arterial blood flow underneath stigmata before and after hemostasis in a recent cohort. Results For natural history, patients with major stigmata treated medically had 65.8% (25/38) rebleeding rates, and 44.7% (17/38) had intervention for hemostasis. Patients with spots or clean bases had no rebleeding. A Doppler probe detected arterial blood flow in 92% of major stigmata—none after hemostasis—and there was no rebleeding. Conclusions (1) Patients with major stigmata treated medically had high rates of rebleeding and intervention for hemostasis. (2) Patients with clean diverticula or only flat spots had no rebleeding. (3) High rates of arterial blood flow were detected under major stigmata with a Doppler probe, but with obliteration by hemostasis no rebleeding occurred. [ABSTRACT FROM AUTHOR]

Background and Aims For more than 4 decades endoscopists have relied on ulcer stigmata for risk stratification and as a guide to hemostasis. None used arterial blood flow underneath stigmata to predict outcomes. For patients with severe peptic ulcer bleeding (PUB), we used a Doppler endoscopic probe (DEP) for (1) detection of blood flow underlying stigmata of recent hemorrhage (SRH), (2) quantitating rates of residual arterial blood flow under SRH after visually directed standard endoscopic treatment, and (3) comparing risks of rebleeding and actual 30-day rebleed rates for spurting arterial bleeding (Forrest [F] IA) and oozing bleeding (F IB). Methods Prospective cohort study of 163 consecutive patients with severe PUB and different SRH. Results All blood flow detected by the DEP was arterial. Detection rates were 87.4% in major SRH—spurting arterial bleeding (F IA), non-bleeding visible vessel (F IIA), clot (F IIB)—and were significantly lower at 42.3% ( P < .0001) for an intermediate group of oozing bleeding (F IB) or flat spot (F IIC). For spurting bleeding (F IA) versus oozing (F IB), baseline DEP arterial flow was 100% versus 46.7%, residual blood flow detected after endoscopic hemostasis was 35.7% versus 0%, and 30-day rebleed rates were 28.6% versus 0% (all P < .05). Conclusions (1) For major SRH versus oozing or spot, the arterial blood flow detection rate by the DEP was significantly higher, indicating a higher rebleed risk. (2) Before and after endoscopic treatment, spurting (F IA) PUB had significantly higher rates of blood flow detection than oozing (F IB) PUB and a significantly higher 30-day rebleed rate. (3) The DEP is recommended as a new endoscopic guide with SRH to improve risk stratification and potentially definitive hemostasis for PUB. [ABSTRACT FROM AUTHOR]

Highlights • Possibly first documented pseudo-transmission from endobronchial ultrasound scope. • Transmission may exist in endoscopes that do not have an elevator channel. • Endoscopes can harbor bacteria despite adherence to reprocessing steps. • Scopes without a leak may have internal damage leading to buildup of biofilm. • Scope culturing protocols may provide a false sense of security. During an investigation of positive environmental cultures with Enterobacter cloacae from an endobronchial ultrasound scope, possible pseudotransmission was discovered between 2 patients. All reprocessing steps were adhered to and the original equipment manufacture's quality control assessment of the scope could not determine the root cause. Our findings appear to be the first documented case of pseudotransmission from an endobronchial ultrasound scope and suggest bacterial transmission may exist in endoscopes without an elevator channel. [ABSTRACT FROM AUTHOR]

Background: Risk factors and outcomes of severe hematochezia from ischemic colitis compared with other colonic diagnoses have not been well studied. Objective: Our purposes were (1) to compare demographics and outcomes of patients hospitalized with severe hematochezia from ischemic colitis compared with other colonic diagnoses, (2) to compare inpatient and outpatient start of bleeding from ischemic colitis, and (3) to describe potential risk factors. Design: Prospective cohort study. Setting: Tertiary referral academic centers. Patients: Patients referred for gastroenterology consultation for severe hematochezia. Interventions: Colonoscopic therapy was provided as indicated. Main Outcome Measurements: Rebleeding, surgery, and length of hospital stay after colonoscopy. Results: Of 550 patients in the past 12 years with severe hematochezia from colonic sources, the cause in 65 patients (11.8%) was ischemia. Ischemic colitis was found more often in females, in patients taking anticoagulant agents, in patients with severe lung disease, those with higher creatinine levels, those with higher glucose levels, and those with more fresh frozen plasma transfusions. Five patients with focal lesions had colonoscopic hemostasis. Major 30-day outcomes of ischemic colitis patients were significantly worse than patients with other colonic diagnoses. Patients with inpatient (vs outpatient) ischemic colitis had significantly more and more severe comorbidities at baseline and significantly higher rates of rebleeding, surgery, and more days spent in hospital and in the intensive care unit. Limitations: Two-center study. Conclusions: Major 30-day outcomes in ischemic colitis patients were significantly worse than in patients with other colonic diagnoses. Comparing outpatient and inpatient start of ischemic colitis, inpatients had significantly worse outcomes. [Copyright &y& Elsevier]

Endoscopic management of acute gastrointestinal (GI) bleeding is an advanced procedure associated with high morbidity and mortality. The traditional apprentice model of training for such events is often inadequate because of their unpredictable frequency, common occurrence off hours, and high stakes for patient outcome. Hemostasis is the cessation of active bleeding and prevention of rebleeding with an endoscopic intervention. Proficiency in endoscopic management of GI hemorrhage includes proper preparation, a systematic categorization of both the source of bleeding and the technique used to control it, the necessary knowledge base, and technical skills to perform the endoscopic intervention. Various simulation platforms, including virtual reality simulators, in vivo models, and explanted tissue, can be helpful in gaining proficiency in endoscopic hemostasis, although validated criteria for obtaining and maintaining procedural competence in this area are still lacking. [Copyright &y& Elsevier]

Background: Several different hemoclips are marketed for endoscopic hemostasis of nonvariceal upper GI (UGI) bleeding. No previous reports have compared success rates of clip deployment onto bases of chronic gastric ulcers (GUs), clip retention rates, or their influence on ulcer healing. Objectives: For the treatment of chronic GUs, to compare 3 different hemoclips with multipolar electrocoagulation (MPEC) and control. Design: Randomized, controlled study. Subjects: Seven adult dogs with prehepatic portal hypertension had GUs created by rubber band ligation. Animals received oral proton pump inhibitors daily and underwent weekly endoscopies to quantitate clip retention and ulcer healing. Interventions: One week after banding, 10 chronic ulcers were randomized in pairs to control (no endoscopic treatment), MPEC, or different hemoclips (QuickClip2 [QC], TriClip [TC], or Resolution Clip [RC]). Main Outcome Measurements: Times and success of hemoclip deployment, clip retention rates, and ulcer healing rates on weekly endoscopies. Results: Success rates of clip deployment were 100% for the RC, 93.1% for the TC, and 83.3% for the QC. Clip retention rates were significantly higher with the RC than the QC or TC at 1 to 3 weeks. Retained clips did not delay GU healing compared with MPEC or control. Conclusions: Hemoclipping time was similar with all 3 clips; the RC was retained significantly longer than the QC or TC, hemoclips did not delay ulcer healing compared with control or MPEC, and all 3 hemoclips were safe and no complications such as bleeding and weight loss were noted. [Copyright &y& Elsevier]

Background & Aims: Nonsteroidal anti-inflammatory drugs (NSAIDs) cause lower gastrointestinal (GI) clinical events such as bleeding. Cyclo-oxygenase (COX)-2 selective inhibitors decrease upper GI events, but no prospective trial has prespecified assessment of lower GI clinical events. Methods: Patients ≥50 years old with osteoarthritis or rheumatoid arthritis were randomly assigned to etoricoxib (60 or 90 mg qd) or diclofenac (150 mg qd). Lower GI clinical events, confirmed by a blinded adjudication committee, included perforation or obstruction requiring hospitalization or bleeding (gross or occult rectal bleeding without upper GI cause associated with hypotension, orthostatic changes in heart rate [>20 beats per minute] or blood pressure [>20 mmHg systolic or >10 mmHg diastolic], hemoglobin drop ≥2 g/dl, or transfusion; or observed active bleeding or stigmata of hemorrhage). Results: We enrolled 34,701 patients with mean duration of therapy of 18 months. Rates were 0.32 and 0.38 lower GI clinical events per 100 patient-years for etoricoxib and diclofenac (hazard ratio [HR] = 0.84; 95% confidence interval [CI], 0.63–1.13). Bleeding was the most common event (rates of 0.19 and 0.23 per 100 patient-years, respectively). Multivariable analysis revealed significant risk factors to be prior lower GI event (HR = 4.06; 95% CI, 2.93–5.62) and age ≥65 years (HR = 1.98; 95% CI, 1.45–2.71). Conclusions: A statistically significant decrease in lower GI clinical events was not seen with the COX-2 selective inhibitor etoricoxib versus the traditional NSAID diclofenac. The risk of a lower GI clinical event with NSAID use seems to be constant over time, and the major risk factors are a prior lower GI event and older age. [Copyright &y& Elsevier]

Background: Mechanical closure of bleeding vessels is clinically appealing, and several types of hemoclips are now marketed for endoscopic hemostasis of nonvariceal lesions. No comparative data have been reported on ease of clip placement, hemostasis efficacy, or clip retention rates on bleeding ulcers. Objective: To compare 3 different types of hemoclips for hemostasis of bleeding ulcers. Design: Randomized controlled study. Subjects: Seven adult dogs with prehepatic portal hypertension were heparinized, and acute gastric ulcers were made with jumbo biopsy forceps. Animals had oral proton pump inhibitors daily and weekly endoscopies to quantitate clip retention and ulcer healing. Interventions: Bleeding ulcers were randomized in pairs (2 for each treatment/dog) to endoscopic hemoclip treatment or control. Main Outcome Measurements: Initial times and success of deployment, hemostasis efficacy, clip retention rates, and ulcer healing during endoscopic follow-ups. Results: There was no difference in initial hemostasis rates of hemoclips, and no major complications occurred. Ulcer healing times were faster (Resolution Clip [RC] or TriClip [TC]) or similar (QuickClip2 [QC]) to controls. Clip retention at 1 week was significantly less with TC and, at 3 to 7 weeks, was significantly higher with RC. Conclusions: (1) For the 3 hemoclip devices, initial hemostasis rates were 100%, but all devices required similar learning time to place clips successfully. (2) Short-term retention rates of TC were significantly less than QC or RC. (3) Long-term clip retention was significantly higher with RC. (4) All 3 hemoclips were safe, and none interfered with ulcer healing. [Copyright &y& Elsevier]

Background & Aims: The optimal management of bleeding peptic ulcer with adherent clot is controversial and may include endoscopic therapy or medical therapy. Methods: We searched MEDLINE, BIOSIS, EMBASE, and the Cochrane Library to identify all randomized controlled trials comparing the 2 interventions. Outcomes evaluated in the meta-analysis were recurrent bleeding, need for surgical intervention, length of hospitalization, transfusion requirement, and mortality. Results: Six studies were identified that included 240 patients from the United States, Hong Kong, South Korea, and Spain. Patients in the endoscopic therapy group underwent endoscopic clot removal and treatment of the underlying lesion with thermal energy, electrocoagulation, and/or injection of sclerosants. Rebleeding occurred in 5 of 61 (8.2%) patients in the endoscopic therapy group, compared with 21 of 85 (24.7%) in the medical therapy group (P = .01), for a pooled relative risk of 0.35 (95% confidence interval, 0.14–0.83; number needed to treat, 6.3). There was no difference between endoscopic therapy and medical therapy in length of hospital stay (mean, 6.8 vs 5.6 days; P = .27), transfusion requirement (mean, 3.0 vs 2.8 units of packed red blood cells; P = .75), or mortality (9.8% vs 7%; P = .54). Patients in the endoscopic therapy group were less likely to undergo surgery (pooled relative risk, 0.43; 95% confidence interval, 0.19–0.98; number needed to treat, 13.3); however, this outcome became nonsignificant when only peer-reviewed studies were considered. Conclusions: Endoscopic therapy is superior to medical therapy for preventing recurrent hemorrhage in patients with bleeding peptic ulcers and adherent clots. The interventions are comparable with respect to the need for surgical intervention, length of hospital stay, transfusion requirement, and mortality. [Copyright &y& Elsevier]

Endoscopy by well-trained and skilled endoscopists yields a definitive diagnosis in over 95% of patients with upper gastrointestinal (UGI) bleeding, and endoscopic hemostasis can be applied in most patients with major stigmata of hemorrhage: active bleeding, nonbleeding visible vessels, or adherent clots. Based on these high rebleeding rates on medical therapy alone, we now recommend endoscopic treatment of all patients with active arterial bleeding, NBVV, and adherent clots. Persistent oozing without other stigmata is also included in this group, although rebleeding rates on medical therapy are substantially lower. In the last 15 years, ulcer hemorrhage has decreased in prevalence, whereas the prevalences of esophagogastric varices and erosive esophagitis have both increased. Heat energy applied through endoscopic probes coagulates tissue proteins, causes edema and vasoconstriction, activates intrinsic arterial (platelet) coagulation, and thereby obliterates the arterial lumen. These contact devices can be applied directly on the ulcer stigmata or the bleeding site to compress the underlying vessel with moderate appositional pressure before coagulation. The pressure on the stigmata interrupts blood flow through the underlying vessel and reduces the heat sink effect. Subsequent applications of low energy, long coagulation with MPEC or heater probe can weld the walls of mesenteric arteries up to 2.0 mm in diameter together for effective “coaptive coagulation” in the laboratory. Combination therapy combines the mechanisms of action for arterial hemostasis of two or more treatment methods. Both epinephrine injection and thermal coagulation activate platelet coagulation and cause tamponade of the vessel. In addition, epinephrine causes vessel constriction, and thermal coagulation probes result in secondary edema and coaptive coagulation. In two recent randomized trials, investigators reported that combination endoscopic treatment with epinephrine injection near the pedicle of the clot in the ulcer base, followed by mechanical shaving down of the clot to expose the underlying stigmata, and subsequent thermal coagulation with MPEC or heater probes, dramatically reduced rebleeding rates compared with medical therapy alone from about 34% to less than about 5%. Combination therapy with epinephrine injection followed by thermal therapies (eg, MPEC or heater probe) has reduced these ulcer rebleeding rates to 15% to 20% for active arterial bleeding and to about 10% for NBVV. In two recent randomized controlled trials, combination epinephrine and thermal therapy (multipolar probe) was also reported to have similar rebleeding rates to hemoclipping for hemostasis of active ulcer bleeding or NBVV. Combination therapy was better than hemoclipping for the subgroup of patients with tangential ulcers. [Copyright &y& Elsevier]

Background & Aims: Standard care for prevention of first esophageal variceal hemorrhage is β-blockade, but this may be ineffective or unsafe. Our purpose was to compare endoscopic banding with propranolol for prevention of first variceal hemorrhage. Methods: In a multicenter, prospective trial, 62 patients with cirrhosis with high-risk esophageal varices were randomized to propranolol (titrated to reducing resting pulse by ≥25%) or banding (performed monthly until varices were eradicated) and were followed up on the same schedule for a mean duration of 15 months. The primary end point was treatment failure, defined as the development of endoscopically documented variceal hemorrhage or a severe medical complication requiring discontinuation of therapy. Direct costs were estimated from Medicare reimbursements and fixed or variable charges for services up to treatment failure. Results: Background variables of the treatment groups were similar. The trial was stopped early after an interim analysis showed that the failure rate of propranolol was significantly higher than that of banding (6/31 vs. 0/31; difference, 19.4%; P = .0098; 95% confidence interval for true difference, 6.4%–37.2%). Significantly more propranolol than banding patients had esophageal variceal hemorrhage (4/31 vs. 0/31; difference, 12.9%; P = .0443; 95% confidence interval for true difference, 0.8%–29%), and the cumulative mortality rate was significantly higher in the propranolol than in the banding group (4/31 vs. 0/31; difference, 12.9%; P = .0443; 95% confidence interval for true difference, 0.8%–29%). Direct costs of care were not significantly different. Conclusions: For patients with cirrhosis with high-risk esophageal varices and no history of variceal hemorrhage, propranolol-treated patients had significantly higher failure rates of failure, first esophageal varix hemorrhage, and cumulative mortality than banding patients. Direct costs of medical care were not significantly different. [Copyright &y& Elsevier]

Portal hypertensive gastropathy (PHG) is an extremely common endoscopic finding in patients with portal hypertension. This article examines the various endoscopic grading systems that have been developed for PHG with further discussion on the risk of bleeding with PHG and if endoscopic grading can predict the risk of bleeding. Finally, both the nonendoscopic and endoscopic treatment modalities for acute and chronic bleeding secondary to PHG are discussed. [Copyright &y& Elsevier]

No prior randomized controlled trial (RCT) has reported patient outcomes of large over-the-scope clip (OTSC) compared to standard hemostasis as initial endoscopic treatment of severe NVUGIB. This was our study aim. Patients with bleeding ulcers or Dieulafoy's lesions and major stigmata of hemorrhage - SRH (active spurting bleeding, visible vessel, or clot) - or lesser SRH (oozing bleeding or flat spots – with arterial blood flow by Doppler probe) were randomized to OTSC or standard endoscopic hemostasis (with hemoclips or multipolar electrocoagulation – MPEC). Patients and their healthcare providers were blinded to treatments and made all post-randomization management decisions. Ulcer patients received high dose intravenous infusions of proton pump inhibitors (PPI) for 3 days, then 27 days of oral PPI. 30 day outcomes were prospectively recorded; data management was with SAS; and data analysis was by a statistician. 53 patients (25 OTSC, 28 Standard) were randomized, with similar baseline risk factors. However, there were significant differences in OTSC vs. Standard groups in rates of rebleeding (4% vs. 28.6%; p =.017; relative risk 0.10, 95% confidence intervals 0.01, 0.91; number needed to treat 4); severe complications (0 % vs. 14.3%); and post-randomization units of red cell transfusions (0.04 vs. 0.68). All rebleeds occurred in patients with major SRH and none with lesser SRH. 1. OTSC significantly reduced rates of rebleeding, severe complications, and post-randomization red cell transfusions. 2. Patients with major stigmata benefited significantly from hemostasis with OTSC, but those with lesser stigmata did not. (ClinicalTrials.gov , Number: NCT03065465). [ABSTRACT FROM AUTHOR]