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Background COVID-19 pandemic is an unprecedented global medical emergency. National and international gastrointestinal societies recommended that any endoscopic activity during the lockdown phase of the pandemic should be limited to emergency or non-deferrable procedures only. We assessed the financial implications and impact on endoscopy activity of the lockdown phase in a tertiary referral endoscopy unit. Methods The number of endoscopy procedures canceled and performed in our endoscopy unit during our "delay phase" (16-22/03/2020) and "lockdown phase" (23/03-29/05/2020) was reviewed and compared with endoscopy activity conducted during the same period in 2019. The financial impact was subsequently analyzed. Results Between 16/03/2020 and 29/05/2020, 683 procedures were canceled and 365 non-deferrable procedures were performed. In contrast, in 2019, 3437 procedures were performed over the same timeframe, resulting in a revenue contraction of approximately €2,062,857. We estimated that the number of lists required to recuperate the canceled endoscopic activity, ranges from 103-155, depending on the level of personal protective equipment required and mitigating policy relating to COVID-19. Conclusion Our results highlight that COVID-19 pandemic had a substantial negative impact on our endoscopy activity and on the revenue generated by our endoscopy unit.

Background and study aims Bowel preparation for colonoscopy is frequently inadequate in hospitalized patients. We explored the impact of specific verbal instructions on the quality of inpatients bowel preparation and factors associated with preparation failure. Patients and methods Randomized (1:1), two strata (mobilized vs. bedridden; 3:2) trial of consecutive inpatients from four tertiary centers, who received either specific, verbal instructions or the standard of care (SOC) ward instructions about bowel preparation. The rate of adequate bowel preparation (Boston Bowel Preparation Score [BBPS] ≥ 6, no segment Results We randomized 300 inpatients (180 mobile) aged 71.7 ± 15.1 years in the intervention (49.7 %) and SOC (50.3 %) groups, respectively. Overall, more patients in the intervention group achieved adequate bowel preparation, but this difference did not reach statistical significance neither in the intention-to-treat [90/149 (60.4 %) vs. 82/151 (54.3 %); P = 0.29] nor in the per-protocol analysis [90/129 (69.8 %) vs. 82/132 (62.1 %); P = 0.19]. Overall BBPS score did not differ statistical significantly in the two groups, but the provision of specific verbal instructions was associated with significant higher rates of good (58.1 % vs. 43.2 %; P = 0.02) and excellent (31.8 % vs. 16.7 %; P = 0.004) bowel preparation compared to the SOC group. Administration of same-day bowel preparation and patient American Society of Anesthesiologists score > 2 were identified as risk factors for inadequate bowel preparation. Conclusions Provision of specific verbal instructions did not increase the rate of adequate bowel preparation in a population of mobilized and bedridden hospitalized patients.

Introduction Clostridium difficile infection (CDI) has been reported to be a cause of flare-ups in patients with inflammatory bowel disease (IBD). Cytomegalovirus (CMV) infection can cause severe disease and complications in immunocompromised patients in consequence of disease or therapy. Aim Our aim was to describe the prevalence and clinical outcomes of CDI with concomitant CMV infection in IBD patients hospitalized for flare-ups in association with the disease itself and medication used. Methods We prospectively identified consecutive patients referred for CDI management during 2015-2017. Stool samples were tested for Clostridium difficile toxin A and/or B and Glutamate Dehydrogenase in patients with clinical symptoms. CDI patients with IBD history were tested for anti-CMV IgG and IgM antibodies by chemiluminescent microparticle immunoassay and underwent histological analysis for CMV on colon biopsies. Data were collected for demographic characteristics, treatment and outcome. Results 125 patients with CDI were enrolled. Among these patients, 14 (11.2%) were diagnosed with IBD. The mean patient age of IBD patients was 52.5±15.4 years at diagnosis of CDI, 85.7% had UC, 14.3% CD, while the age of patients was shared. Eleven of the total of 14 patients (78.6%) tested positive for anti-CMV IgG. Of these, 3 patients (21.4%) exhibited high CMV IgG avidity, without detectable anti-CMV IgM and biopsy-proven CMV colitis. Of the 14 IBD patients with CDI, 8 patients (57.1%) were receiving anti-tumor necrosis factor (anti-TNF) therapy (21.4 % infliximab or golimumab, 7.1% vedolizumab or adalimumab) and 43.5% of patients were being treated with systemic corticosteroids. Four UC patients (28.6%) on steroids of the 14 CDI patients underwent a colectomy whereas none of the not on steroids patients underwent colectomy (p=0.25). Among them, 1 patient (7.1%) had recurrent CDI after 5 months from the first episode of CDI.These patients were treated with vancomycin, metronidazole and fidaxomicin. The mean age of patients that had a colectomy 65.5±9.32 (n=4) was higher than the mean age of those 47.30±14.49 (n=10) who improved (UMann-Whitney=6. p=0.04). Conclusions Immunosuppressive medications and older age are associated with increased risk of CDI and poor outcome. Although, CMV is a rare colonic pathogen in the immunocompetent patient, it should be included and screened when exacerbation of IBD occurs in patients receiving any type of immunosuppressive therapy.

Primary sclerosing cholangitis (PSC) is a chronic and progressive disease of the biliary tract. PSC is strongly associated with inflammatory bowel disease (IBD), mainly with ulcerative colitis, and most PSC patients have underlying IBD. The pathophysiological interactions between IBD and PSC are unclear, although it seems that the patients with IBD and PSC have a distinct phenotype. IBD with coexisting PSC is more extensive and is characterized by milder activity compared to IBD alone. The coexistence of PSC increases the risk for colorectal cancer in IBD patients and lifelong annual surveillance colonoscopy is recommended. Also, liver transplantation (LT) for PSC may affect the course of IBD. In addition, the management of IBD after LT includes many specific problems. On the other hand, the effect of IBD on the natural history of PSC appears to be milder. However, IBD may increase the risk of postsurgical complications after LT and is a risk factor for recurrent PSC after LT. Overall, the coexistence of IBD with PSC changes the management, natural history and prognosis of both diseases.

Introduction: Patients with ulcerative colitis (UC) can suffer from low serum vitamin D that can result in complications such as low bone mineral density. It can also reflect underlying disease severity. Methods: One hundred and ninety-seven patients previously diagnosed with UC from 2 European centers were prospectively recruited through the out-patient clinics. Clinical features (Montreal Classification, age, gender, previous and current medications, surgery), disease activity (Simple Clinical Colitis Activity Index [SCCAI]), blood investigations including serum inflammatory markers, and serum vitamin D were analyzed. The vitamin D levels were compared to a group of age- and gender-matched healthy controls. Results: Mean vitamin D levels were lower in patients with UC (54.6 nmol/L) than in controls (80.7 nmol/L; p = 0.0001). Mean vitamin D levels was lowest in patients with extensive UC (E3; p = 0.0001). Serum vitamin D was not significantly different across treatment groups (p = 0.876). There was no statistical difference in vitamin D levels across patients receiving calcium and vitamin D supplements (p = 0.35) and there was no statistical correlation with SCCAI (p = 0.22). Conclusions: This study confirms the existence of low serum vitamin D in patients with UC when compared to healthy controls. It also provides evidence of an existing relationship between disease extent and serum vitamin D.

Lipomas of the gastrointestinal (GI) tract are common, benign and usually present as innocuous findings. Larger ones (>2 cm in diameter), particularly those involving the ileum, may present with clinical symptoms such as abdominal pain (caused by intussusception) and iron deficiency anaemia (IDA) or obscure GI bleeding (OGIB) (caused by overlying mucosal ulceration); these cases warrant intervention and often end up being referred for surgery. We describe a minimally invasive endoscopic alternative to surgical resection for the management of these lesions. A 60-year-old man presented with recurrent, cramping abdominal pain and OGIB. A magnetic resonance enterography (MRE) revealed a 2.5 cm submucosal lesion in the distal ileum, in keeping with a large lipoma. In light of these findings and the clinical presentation, we perform a saline-immersion retrograde DBE under conscious sedation, for further evaluation and minimally invasive, definitive endotherapy. At DBE the lesion was identified at around 40 cm proximal to the ileocaecal valve. The endoscopic appearances revealed a 2.5 cm sessile submucosal, lumen-filling lesion with a positive ‘pillow sign’. Although the overlying mucosa appeared mostly unremarkable, a small, healed ulcer (which would account for the patient’s IDA and OGIB) was identified on the medial surface of the lesion. Endotherapy was deemed feasible and this was facilitated by the buoyancy properties provided by SITE. In order to reduce the risk of perforation and bleeding, an endoscopic loop ligating device was first deployed tightly at the base of the lesion. A ball-tip, needle-type endoscopic submucosal dissection (ESD) knife was then used to incise and unroof the lesion. This allowed for exposure and spontaneous extrusion of the lipomatous tissue (already under pressure from the loop-lighting device). Saline-immersion allowed for maintenance of a clear visual field, through avoidance of clouding of the endoscopic lens and flotation of extruded micelles of fatty tissue. A submucosal tattoo and a clip were placed as endoscopic and radiological markers, respectively. The procedure was performed under antibiotic cover. No significant immediate, early or late adverse events were encountered. Histopathological examination of retrieved tissue showed mature adipocytes with fibrofatty submucosal changes, in keeping with a submucosal lipoma. No dysplasia or sarcomatous transformation was identified. The patient’s symptoms have resolved completely post-endotherapy. Our case demonstrates the safety and usefulness of minimally invasive endotherapy of symptomatic large ileal lipomas. The combination of DBE with SITE-facilitated unroofing, after securing the lipoma’s base with a loop-ligation device, allows for safe, spontaneous extrusion of the benign lipomatous tissue and avoids the need for operative surgery in symptomatic patients.

The impact of small-bowel (SB) capsule endoscopy and device-assisted enteroscopy on clinical practice, since their introduction 2 decades ago, has been remarkable. These disruptive technologies have transformed the investigation and management of SB pathology and now have a firmly established place in guidelines and clinical algorithms. Furthermore, recent years have witnessed innovations, driven by the demand of new goals in the management of inflammatory bowel disease (IBD), such as mucosal healing and evolving strategies based on tight monitoring and accelerated escalation of care. These developments in SB endoscopy have also been paralleled by refinement in dedicated radiological SB imaging technologies. This updated review highlights the current state of the art and more recent innovations with a focus on their role in IBD.

Optimisation of patient care though multidisciplinary team (MDT) meetings is now established as the standard of care in cancer pathways. Cases presented at MDTs are discussed by a panel of experts in order to provide optimal management. An ‘Advanced-endoscopy MDT’ may help to achieve consensus on decision-making, clinical outcomes and patient satisfaction. In our tertiary referral institution, we developed and adopted an ‘Advanced-Endoscopy MDT’ to evaluate complex cases. A bi-weekly meeting was established with the presence of expert interventional endoscopists, radiologists, histopathologists, dedicated gastrointestinal surgeons and nurse endoscopists. Depending on the cases discussed, additional experts were also in attendance. Endoscopic images, radiological scans and histopathology reports were assessed in order to decide treatment options and surveillance intervals. We retrospectively reviewed all patients that were discussed. Demographic, clinical, endoscopic findings and outcome data were analysed. Over 20 months, 35 meetings were conducted; 463 cases were discussed for a total of 323 patients. The main reasons for MDT referral were for consideration of double-balloon enteroscopy (DBE) (107 patients) and for appropriate endoscopic or surgical management of mucosal/submucosal GI lesions. Through MDT discussion, 9 patients were referred for surgical management; 34 patients were treated with endoscopic submucosal dissection (ESD) and 72 patients with endoscopic mucosal resection (EMR). One ESD procedure was abandoned due to high suspicion of deep invasion and was referred for surgery. From the remaining 33 cases, R0 margins were reported for 32/33 patients. Eight patients referred for DBE did not require endoscopic input and 29 cases were reviewed twice as additional radiological investigations or small bowel capsule endoscopy were deemed necessary. No major adverse event including perforation, severe delayed GI bleed or sepsis occurred after any endoscopic procedure discussed at the MDT. Based on our preliminary experience of an ‘Advanced-Endoscopy MDT’ is a useful platform for the safe, effective and efficient management of complex advanced endoscopic procedures.

Background and study aims Bowel preparation for colonoscopy is frequently inadequate in hospitalized patients. We explored the impact of specific verbal instructions on the quality of inpatients bowel preparation and factors associated with preparation failure. Patients and methods Randomized (1:1), two strata (mobilized vs. bedridden; 3:2) trial of consecutive inpatients from four tertiary centers, who received either specific, verbal instructions or the standard of care (SOC) ward instructions about bowel preparation. The rate of adequate bowel preparation (Boston Bowel Preparation Score [BBPS] = 6, no segment < 2) comprised the primary endpoint. Mean BBPS score, good (BBPS score = 7, no segment score < 2) and excellent (BBPS = 9) were among secondary endpoints. Results We randomized 300 inpatients (180 mobile) aged 71.7 +/- 15.1 years in the intervention (49.7%) and SOC (50.3%) groups, respectively. Overall, more patients in the intervention group achieved adequate bowel preparation, but this difference did not reach statistical significance neither in the intention- to- treat [90/149 (60.4%) vs. 82/151 (54.3%); P = 0.29] nor in the per-protocol analysis [90/129 (69.8%) vs. 82/132 (62.1%); P = 0.19]. Overall BBPS score did not differ statistical significantly in the two groups, but the provision of specific verbal instructions was associated with significant higher rates of good (58.1% vs. 43.2%; P= 0.02) and excellent (31.8% vs. 16.7%; P = 0.004) bowel preparation compared to the SOC group. Administration of same-day bowel preparation and patient American Society of Anesthesiologists score > 2 were identified as risk factors for inadequate bowel preparation. Conclusions Provision of specific verbal instructions did not increase the rate of adequate bowel preparation in a population of mobilized and bedridden hospitalized patients.

Background: Inflammatory bowel diseases (IBD), ulcerative colitis (UC), and Crohn&rsquo, s disease (CD), represent systematic chronic conditions with a deficient intestinal absorption. We first attempt to investigate the serum bile acids (sBAs) profile in a large cohort of IBD patients to evaluate changes under anti-TNF alpha treatment. Methods: Forty CD and 40 UC patients were enrolled and BAs were quantified by high-pressure liquid chromatography-electrospray-tandem mass spectrometry (HPLC-ES-MS/MS). Up to 15 different sBAs concentrations and clinical biomarkers where added to a Principal Component Analysis (PCA) to discriminate IBD from healthy conditions and treatment. Results: PCA allowed a separation into two clusters within CD (biologic-free patients and patients treated with anti-TNF alpha drugs and healthy subjects) but not UC. The first included CD. CD patients receiving anti-TNF alpha have an increase in total sBAs (4.11 1.23 &mu, M) compared to patients not exposed. Secondary BAs significantly increase after anti-TNF alpha treatment (1.54 0.83 &mu, M). Furthermore, multivariate analysis based on sBA concentration highlighted a different qualitative sBAs profile for UC and CD patients treated with conventional therapy. Conclusion: According to our results, anti-TNF alpha in CD restores the sBA profile by re-establishing the physiological levels. These findings indicate that, secondary BAs might serve as an indirect biomarker of the healing process.