American Journal of Gastroenterology

Background and AimsEmergency admission with foreign body in the oesophagus (FBO) commonly requires endoscopic removal. Oesophageal food bolus obstruction is often due to eosinophilic oesophagitis (EoE). Patients with food bolus obstruction should undergo endoscopy and multilevel oesophageal biopsies to exclude EoE. This national retrospective study examined the management, including endoscopy and follow-up, of patients presenting as an emergency with FBO. MethodsThe Hospital Episode Statistics database was used to identify patients over 18 with FBO presenting as an emergency in England using the ICD-10 code T18.1 between 2008 and 2019. Logistic regression analysis was used to assess factors associated with undergoing endoscopy and biopsy. Results27,063 patients were identified: 65.5% male; median age 57(IQR 41-73) years; and 47.2% were admitted under Ear, Nose & Throat (ENT). 75.7% underwent endoscopy (94% within a week of admission) but only 19.8% had biopsies taken within 6 months of admission. 0.4% were coded with a perforation related to endoscopy for FBO. 70% of ENT patients underwent endoscopy but only 11.9% had biopsy to exclude EOE, compared with 83% of patient admitted under General Medicine undergoing endoscopy and 29.5% biopsy. Endoscopy and biopsy was associated with: older age (e.g. 61-70 OR 1.42 (95% CI 1.26-1.61)), males (females 0.67(0.62-0.72)), the least deprived (1.25 (1.13-1.38)), later diagnosis year (2019 1.42 (1.21-1.66)), and admission under General Medicine (2.68(2.48-2.88)) or Gastroenterology (3.03(2.61-3.51)) but not with NHS trust FBO volume. 33.4% received relevant outpatient follow-up within 12 months of FBO admission: 26% of patients admitted under General Medicine were referred to gastroenterology for follow-up, but only 12.1% of those admitted under ENT. Conclusions75.7% of patients presenting with FBO undergo endoscopy but few (19.8%) had biopsies taken to exclude this common presentation of EOE. Pathways for the management of food bolus obstruction require re-design and unless the airway is impaired, this condition should be managed under General Medicine.

IntroductionVonoprazan, a new oral potassium-competitive acid blocker (PCAB), has shown promise in terms of superior acid suppression when compared to Proton-pump inhibitors (PPIs). We evaluated the efficacy of PCABs versus PPIs in preventing rebleeding in high-risk peptic ulcer patients after endoscopic hemostasis. MethodsFollowing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a comprehensive search for relevant studies across Medline, Embase, Web of Science, Cochrane Central Register of Controlled Trials and ClinicalTrials.gov, from inception till March 25, 2025. The primary outcome of interest was peptic ulcer rebleeding rate. Pooled risk ratios (RR) and mean difference (MD) with the corresponding 95% confidence intervals (CIs) were calculated. ResultsThree studies with 54,410 patients receiving endoscopic hemostasis for peptic ulcer bleeding were included in our analysis. The mean age of included participants was 71 {+/-} 1.83 years. There was no significant difference in rebleeding rates between patients receiving PPIs and PCABs (RR 0.827; 95 % CI: 0.5 -1.3). We observed a significant reduction in length of hospital stay in the PCAB group when compared to the PPI group (MD: -0.44, 95% CI: -0.72 - -0.17), but no significant difference in all-cause mortality between both groups (RR: 0.90, 95% CI: 0.79 - 1.04). ConclusionsOur study demonstrates comparable efficacy of PPIs and PCABs in preventing rebleeding in patients with high-risk peptic ulcers after successful endoscopic hemostasis. However, there was a significant reduction in hospital length of stay favoring PCABs. Research in ContextO_ST_ABSWhat is already known on this topicC_ST_ABSBleeding from peptic ulcers is considered one of the major reasons for mortality and hospitalization, and the standard treatment after endoscopic hemostasis is the administration of high-dose proton pump inhibitors (PPIs). Potassium competitive acid blockers (PCABs), such as vonoprazan, have been reported to have more potent and faster onset of action than PPIs in the treatment of acid-related diseases, but their efficacy in the prevention of post-endoscopic peptic ulcer rebleeding has not been well established in the literature in the form of a dedicated meta-analysis. What this study addsIn the present study, the efficacy and safety of PCABs in the prevention of post-endoscopic rebleeding and mortality in 54,410 patients with high-risk peptic ulcer bleeding were investigated in the context of a systematic review and meta-analysis. PCABs were found to have similar efficacy to PPIs in the prevention of mortality and rebleeding in the context of endoscopic hemostasis, and the use of PCABs was also observed to reduce the length of stay in the hospital to a significant extent. How this study might affect research, practice or policyThese findings indicate that PCABs are a reasonable alternative to PPIs in post-endoscopic management of high-risk peptic ulcer bleeding and may be particularly useful in situations where early discharge and optimization of resources are critical. Additional large-scale studies in different populations are required to validate these findings and create guidelines

ObjectivePrevalence of anemia in persons with spinal cord injury is higher than their able-bodied counterparts at 50-80%. The etiology is multifactorial but likely related to chronic whole-body inflammation. Chronic anemia is often an indication of gastrointestinal blood loss leading to a diagnostic colonoscopy. However, colonoscopies in persons with spinal cord injury are not without complications. We tested the hypothesis that, despite a high incidence of anemia, performing a colonoscopy in persons with spinal cord injury has a high complication rate and low rate of finding high risk pathology. DesignRetrospective chart review Subjects41 persons with chronic spinal cord injury admitted for colonoscopy from 2019-2024. MethodsPercent of complications and abnormal findings were calculated. A logistic regression model determined predictors of complications and abnormal findings. ResultsAnemia prevalence was 59.1% with a complication rate of 38.6% and 59 abnormal findings in 95.2% of CSPs (n=4 (6.8%), high-risk pathology). Persons with anemia had a higher risk of complications and a decreased risk of hemorrhoids. ConclusionIn persons with spinal cord injury, given a low-rate high risk pathology in the setting of a high complication rate, especially in persons with anemia, the risk of complications should be weighed more heavily in the decision to perform a colonoscopy.

ObjectiveTo identify independent risk factors for early ([≤]7-day) re-bleeding after peptic ulcer bleeding (PUB) and to compare the predictive performance of Forrest classification, Complete Rockall Score (CRS), and Glasgow-Blatchford Score (GBS). MethodsWe retrospectively analyzed adults with endoscopy-confirmed peptic ulcer bleeding from 2015-2020. Early re-bleeding was defined as [≤]7 days after index hemostasis. We applied univariable and multivariable logistic regression and assessed discrimination with ROC curves (AUC). ResultsIndependent risk factors for early re-bleeding included: heart rate (OR 1.054), hemoglobin (OR 1.878), erythrocyte distribution width (OR 1.171), degree of ulcer erosion (OR 1.191), and blood transfusion intervention (OR 12.296). Forrest showed the best discrimination (AUC 0.775; sensitivity 96.2%; specificity 58.8%), followed by GBS (AUC 0.670) and CRS (AUC 0.507) ConclusionsHeart rate, hemoglobin, erythrocyte distribution width, ulcer erosion, and blood transfusion are significant risk factors for early re-bleeding in PUB. Forrest grading is the most effective predictor, while GBS can stratify risk and may benefit from modifications. CRS showed limited predictive utility. Limitationssingle-center, retrospective design; possible residual confounding; no external validation. Clinical implicationsForrest can guide intensified monitoring/hemostasis; GBS supports pre-endoscopy triage; CRS adds limited value.

BackgroundAntithrombotic drugs were widely used for cardiovascular disease prevention, but their association with nonbiliary acute pancreatitis remains unclear. AimThis study aimed to investigate the association between regular antithrombotic drug use and the risk of nonbiliary pancreatitis in the UK Biobank. MethodsThis prospective cohort study included 431,754 participants from the UK Biobank. Incident nonbiliary acute pancreatitis was identified through links to primary healthcare and hospitalization data. The Cox proportional hazards model estimated the relationship between antithrombotic drug use and nonbiliary acute pancreatitis risk. ResultsDuring a median follow-up period of 13.73 years, 2,189 nonbiliary acute pancreatitis cases were recorded. Antithrombotic users had a 31% higher risk of nonbiliary acute pancreatitis than non-users (HR = 1.31, 95% CI: 1.08 - 1.61, p = 0.007). Risk varied by specific agent: clopidogrel was associated with a 53% increased risk (HR = 1.53, 95% CI: 1.08 - 2.16, p = 0.016). For warfarin, the overall association was not statistically significant (HR = 1.32, 95% CI: 0.97 - 1.80, p = 0.076); however, subgroup analysis indicated that the association was confined to non-diabetic individuals (P-interaction = 0.015; HR = 1.64, 95% CI: 1.15 - 2.35, p = 0.007). No significant associations were observed for low-dose aspirin and dipyridamole. These results remained robust in sensitivity analyses, including propensity score matching analysis and lagging the exposure for one year. ConclusionsRegular use of antithrombotic drugs, especially clopidogrel, was associated with an increased risk of nonbiliary acute pancreatitis. The risk associated with warfarin was specific to non-diabetic individuals.

BackgroundChronic nausea and vomiting syndromes (CNVS), gastroparesis and functional dyspepsia (FD) are complex disorders. Body Surface Gastric Mapping (BSGM), a new test of gastric function, using Gastric Alimetry(Alimetry, New Zealand) may be useful for de-escalating healthcare utilisation. This study aimed to define healthcare costs and estimate health economic impacts of implementing this test in patients with chronic gastroduodenal symptoms. MethodsConsecutive patients at a tertiary referral centre evaluated with Gastric Alimetry were included. Frequency and cost data relating to medical investigations, hospital, and outpatient presentations were evaluated. Costs of healthcare utilisation were calculated, and the potential cost savings of implementing Gastric Alimetry within a diagnostic decision-tree model were estimated. ResultsOverall, 31 consecutive patients (mean age 36.1 years; 83.9% female; predominant symptoms: nausea [83.9%], pain [61.3%], vomiting [67.7%], bloating [35.5%]) completed Gastric Alimetry testing. Repeat gastroscopy and abdominal CT rates were 29% (8/28) and 85% (11/13) respectively. Gastric Alimetry testing identified spectral abnormalities in 45.2% of patients, and symptom profiling classified a further 29.1% of patients. Median annualised cost difference after test introduction was NZ$-12,032. Estimated reductions in investigation-related costs when incorporating Gastric Alimetry into the diagnostic workflow model were approximately NZ$1,500 per patient. ConclusionsHealthcare utilisation and confirmatory testing rates remain high in nausea and vomiting syndromes. This study presents real-world data, together with a decision tree analysis, showing Gastric Alimetry can streamline clinical care pathways, resulting in reduced healthcare utilisation and cost.

INTRODUCTIONPatients with chronic constipation exhibit symptoms and motility abnormalities that occur in combinations, but the nature of these combinations has not been characterized. METHODSWe calculated prevalences of combinations of symptoms (abdominal pain, infrequent defecation, incomplete evacuation, straining), abnormal motility test results (prolonged colonic transit time, low anal basal pressure, low anal squeeze pressure, poor rectal sensation, absent balloon expulsion), or both using data from 75 females and 91 males with chronic constipation. We calculated the "Cluster Factor" as observed prevalence of a combination of symptoms, abnormal test results or both divided by the prevalence of the combination due to chance. We calculated the conditional probabilities of combinations of symptoms, abnormal motility test results or both given the prevalence of other members of the same combination. RESULTSCombinations of symptoms alone or abnormal motility test results alone in both males and females, and for combinations of symptoms plus abnormal motility test results in females, failed to cluster together beyond that attributable to chance alone. Males, however, showed significant clustering. Significant conditional probabilities with symptoms, and with symptoms plus abnormal motility test results was higher in males than females. Significant conditional probabilities with abnormal motility test results were not different between males and females. CONCLUSIONSGender-related differences in prevalences of combinations of symptoms and abnormal motility test results, of significant Cluster Factors, and of conditional probabilities indicate that chronic constipation in males reflects a fundamentally different disorder from that in females.

IntroductionAchalasia is a rare primary esophageal motility disorder characterized by impaired lower esophageal sphincter relaxation and dysphagia. Laparoscopic Heller myotomy (LHM) has long been the standard treatment, while peroral endoscopic myotomy (POEM) has emerged as a minimally invasive alternative. Comparative evidence from randomized controlled trials (RCTs) remains limited, and outcomes such as gastroesophageal reflux disease (GERD) and clinical remission require clarification. MethodsWe systematically searched PubMed, Embase, Cochrane CENTRAL, and Web of Science to September 2025 for RCTs comparing POEM and LHM in adult patients with achalasia. Data on demographics, previous treatment, dysphagia improvement, GERD incidence, clinical remission, and mortality were extracted. Pooled odds ratios (OR) with 95% confidence intervals (CI) were calculated using a random-effects model in Stata 18. ResultsSeven RCTs involving 900 patients (465 POEM; 465 LHM) were included. Dysphagia improvement was similar between groups (log OR 0.14; 95% CI -0.32 to 0.59; p = 0.55). GERD incidence was higher after POEM but not statistically significant (log OR 0.59; 95% CI -0.08 to 1.25; p = 0.08). Clinical remission showed a non-significant trend favoring POEM (log OR 0.39; 95% CI -0.06 to 0.84; p = 0.09). Reduction in pH levels significantly favored LHM (log OR 0.75; 95% CI 0.18 to 1.33; p = 0.01). No mortality was reported. ConclusionPOEM and LHM provide comparable dysphagia relief and clinical remission in achalasia. However, POEM is associated with higher GERD risk, particularly on pH monitoring. Treatment choice should balance efficacy against reflux risk, with careful long-term follow-up.

Background and PurposeNonvariceal upper gastrointestinal bleeding (gastrointestinal) is potentially life-threatening. The study aimed to evaluate the clinical outcome in patients with upper gastrointestinal bleeding with a prior history of ischemic stroke. MethodsThe 2021 National Inpatient Sample database was employed to identify 259025 patients diagnosed with non-variceal upper gastrointestinal bleeding. 1485 patients exhibited a prior diagnosis of ischemic stroke. Data analysis was conducted using Stata version 18 to determine the primary outcome of mortality and secondary outcomes of length of hospitalization, cost, and post-hospitalization care needs. Results259025 patients exhibited admissions due to non-variceal upper gastrointestinal bleed, and 1485 (0.57%) patients exhibited prior diagnoses of ischemic stroke. Patients with a history of ischemic stroke had a mean age was 72.35 years with higher comorbidities. Patients with a prior history of ischemic stroke had a higher risk of in-hospital mortality (OR 7.51,p<0.01). Length of hospitalization was longer by an mean of 5.68 days (p<0.01), and a higher need for discharge to a skilled nursing facility (OR 3.30, p<0.01). Race, median annual income, and geographical distribution were statistically noncontributory to the outcomes. ConclusionPatients with a history of ischemic stroke who present with non-variceal upper gastrointestinal bleeding tend to be older and have a higher comorbidity index. Prior history of stroke is an independent factor that contributes to the increased mortality in patients presenting with non-variceal upper gastrointestinal bleeding. They experience increased mortality rates, prolonged hospitalizations, higher costs during hospitalization, and a greater likelihood of being discharged to a nursing facility.

BackgroundLuminal application of 5-HT4 receptor agonists can increase peristalsis in the guinea pig, mouse, rat and rabbit colon. Our aim in the present study was to test the effects of intraluminal prucalopride on motor patterns in the human colon. MethodsColonic motor patterns were studied in vivo in a healthy volunteer using High-Resolution Colonic Manometry (HRCM) with an 84-sensor water perfused catheter with 1cm spacing. 5-HT and 5-HT4 receptor immunohistochemistry was performed on human tissue biopsies throughout the colon. Key resultsActivating mucosal 5-HT4 receptors via intraluminal prucalopride enhanced propulsive motor activity in the human colon by increasing occurrence and amplitude of propulsive motor patterns including high-amplitude propagating pressure waves (HAPWs), pancolonic simultaneous pressure waves (SPWs) and HAPW-SPWs. Prucalopride-induced motor patterns had a close temporal association with a significant degree of anal sphincter relaxation and some were accompanied by a strong urge to defecate. Biopsies showed 100% colocalization of the 5-HT4 receptor to enterochromaffin cells throughout the colon and rectum. Conclusions and inferencesActivating luminal 5-HT4 receptors on enterochromaffin cells by intraluminal prucalopride increased propulsive motor activity. 5-HT4 receptors were found only on enterochromaffin cells and not ubiquitous on all epithelial cells. Our data support incorporation of prucalopride in colon-specific drug delivery systems as a prokinetic to treat colonic hypomotility disorders. 50 word abstractHigh-resolution colonic manometry and biopsy immunohistochemistry revealed that 5-HT4 receptors in the lumen of the human colon are present exclusively on enterochromaffin cells and that the 5-HT4 agonist prucalopride evokes all major propulsive motor patterns, associated with significant anal sphincter relaxation, when given intraluminally. 250-character clinical messageActivating luminal 5-HT4 receptors on enterochromaffin cells by intraluminal prucalopride increased propulsive motor activity in the human colon. Colon-specific delivery systems with a 5-HT4 agonist may become the preferred colon prokinetic.

BackgroundThe Lyon Consensus identified distinct phenotypes of symptomatic GERD subjects: NERD, reflux hypersensitivity, and functional heartburn; however, the Consensus did not describe a relationship between esophageal acid exposure and symptom frequency. ObjectiveThe present analyses aim to examine this relationship in ways that capture the variation among individual GERD subjects. DesignRecords of symptoms and 24-hour esophageal pH from 60 subjects with a normal upper endoscopy were grouped using the Lyon criteria for the three phenotypes of GERD (20 subjects per phenotype). Interval esophageal acidity was calculated before each symptom from 24-hour pH recordings. The value for symptom frequency was plotted versus the corresponding value for esophageal acid for each subject on a graph divided into quadrants based on the median value for symptom frequency and esophageal acid from all 60 subjects. Thus, each subject was categorized as esophageal acid: symptom frequency as high: high; high: low; low: high or low: low. ResultsSubjects were distributed among all 4 quadrants, and each quadrant tended to cluster a specific Lyon Consensus phenotype (Chi-Square P=0.00018). There was a significant discordant relationship between esophageal acid and symptom frequency in 63% of subjects (high:low or low:high; binomial probability = 0.0123). ConclusionsThe quadrant classification captures the essential variation in GERD subjects, aligns with phenotype groupings, reflects symptom burden (which phenotypes ignore), and maps more directly to possible treatment decisions. Given its simplicity and interpretability, a quadrant-based diagnosis and subsequent treatment choice may provide a pragmatic, evidence-based approach in routine clinical care.

BackgroundEosinophilic Esophagitis (EoE) is a chronic inflammatory condition diagnosed by [&ge;]15 eosinophils (Eos) per high-power field (HPF). There is no gold standard for clinical remission and Eo-associated metrics are poorly correlated with symptoms. Deep learning can be used to explore the relationships of tissue features with clinical response. ObjectivesTo determine if deep learning can elucidate tissue patterns in EoE that predict treatments or symptoms at remission. MethodsWe created two deep learning models using esophageal biopsies from histologically normal and EoE patients: one to identify Eos in esophageal biopsies and a second to broadly classify esophageal tissue as EoE vs. normal. We used these models to analyze biopsies at diagnosis and first remission timepoint, as defined by <15 Eos/HPF, in a subset of 19 treatment-naive patients. Differences in deep learning metrics between patient groups were assessed using Wilcoxon Rank-Sum tests. ResultsAll initial patients were symptomatic at diagnosis and a majority were still suffering from dysphagia at remission. The Eo identification model had a low mean (SD) error of -0.3 (11.5) Eos/HPF. Higher peak and average Eo counts at diagnosis were associated with higher likelihood of being on a food-elimination diet at remission than steroids or proton-pump inhibitor (p<0.05). The EoE classification model had an F1-score of 0.97 for distinguishing normal tissue from EoE. There was a significant decrease from diagnosis in the percentage of EoE-classified tissue among asymptomatic remission patients (p<0.05). ConclusionsDeep learning may have utility in diagnosing EoE and predicting future treatment response at diagnosis and resolution of symptoms at follow-up. Clinical Implications or Key Messages (for mechanistic article)We developed two deep learning approaches for tissue analysis in eosinophilic esophagitis, which may improve histologic assessment of patients at diagnosis and predict treatment response and symptoms at remission. Capsule summaryTwo deep learning approaches for eosinophilic esophagitis (EoE): (1) Quantification of eosinophils throughout an entire biopsy, which predicted treatment at remission (2) Classifying esophageal tissue as EoE or normal, which predicted symptoms at remission.

IntroductionEosinophilic oesophagitis (EoE) is a chronic, immune-mediated disease characterized by oesophageal dysfunction and mucosal eosinophilia. Conventional therapies, including dietary elimination, proton pump inhibitors, and topical corticosteroids, are often insufficient or associated with relapse, highlighting the need for targeted treatments. Biologic agents modulating type 2 inflammation have emerged as promising options. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to evaluate the efficacy and safety of biologics in EoE. MethodsElectronic databases (PubMed, Embase, CENTRAL, Web of Science, Scopus) and trial registries were searched from inception to [insert date]. Eligible studies were double-blind RCTs comparing biologics with placebo in EoE. Data extraction and risk-of-bias assessment (RoB 2.0) were performed independently by two reviewers. Pooled analyses were conducted using random-effects models, reporting log odds ratios (OR) or risk ratios (RR) with 95% confidence intervals (CIs). Certainty of evidence was rated with GRADE. ResultsA total of 1,706 patients (1,046 males and 696 females; mean age 56.1 {+/-} 15 years; mean follow-up 9.2 months) from 14 randomized controlled trials were included, with 982 patients receiving biologics and 723 assigned to placebo. Biologics significantly increased histological remission compared with placebo (log OR 1.57, 95% CI 0.55-2.60; I{superscript 2} = 89.6%), with benralizumab and lirentelimab demonstrating the strongest effects, while dupilumab showed variable histological outcomes but consistent symptomatic benefits in pivotal trials. Symptomatic response did not improve significantly overall (log OR 0.18, 95% CI -0.73-1.09), although benralizumab showed benefit and lirentelimab trended negatively. Endoscopic remission was not significantly different between biologics and placebo (log OR -0.38, 95% CI -1.56-0.79). Safety analyses revealed no overall increase in adverse events (log RR -0.10, 95% CI -0.40-0.19), with etarsimod and reslizumab associated with fewer events, while lirentelimab suggested a possible increase in cardiological adverse events. Neurological adverse events were infrequent and comparable to placebo. ConclusionBiologic therapies are effective in achieving histological remission in EoE, with benralizumab, lirentelimab, and dupilumab showing the greatest promise. Symptomatic and endoscopic benefits are less consistent, underscoring the need for standardized outcome measures. Biologics were generally safe, with no overall increase in adverse events. These findings support the expanding role of biologics in EoE management while highlighting the importance of long-term and head-to-head trials to optimize therapeutic strategies.

Background and AimsTraditional guidelines recommend delayed feeding after percutaneous endoscopic gastrostomy (PEG) because of concerns about postprocedural complications. Early feeding is safe after pull-technique PEG; however, optimal timing after push-technique PEG remains uncertain. We evaluated the safety and efficacy of early vs delayed feeding after push-technique PEG, focusing on maximal gastric residual volume, complications, and wound site bacterial colonization. MethodsA randomized noninferiority trial was conducted at a university hospital in 160 patients undergoing successful push-technique PEG placement between February 2022 and June 2023. Patients were randomized 1:1 to early feeding (<4 hours) or delayed feeding (>12 hours). Both groups received identical intermittent drip-feeding protocols. The primary outcome was maximal gastric residual volume. Secondary outcomes were length of stay, opioid consumption, postprocedural complications, and wound culture. ResultsMedian time to feeding was 2.2 hours (0.7-4.0) in the early group and 17.2 hours (12.8-40.5) in the delayed group. Maximal gastric residual volume did not differ between groups (0 vs 0 mL; P=0.26). Early feeding reduced hospital stay (42.3 vs 46.0 hours; P<0.01) and opioid use (2.0 [0-10] vs 2.0 [0-12] mg; P=0.01). Rates of complications (fever, bleeding, wound infection, abdominal distension) were comparable (20.0% vs 27.5%; P=0.35). Wound cultures showed no significant difference in bacterial colonization (26.3% vs 22.5%; P=0.58). ConclusionsEarly enteral feeding within 4 hours after push-technique PEG is safe, does not impair gastric emptying, and reduces hospital stay and opioid use. These findings extend the evidence for early feeding to push-technique procedures. Trial RegistrationThai Clinical Trials Registry. Registration number TCTR20220105003. Web link: https://www.thaiclinicaltrials.org/show/TCTR20220105003.

Background and AimGuidelines recommend risk stratification scores in patients presenting with gastrointestinal bleeding (GIB), but such scores are uncommonly employed in practice. Automation and deployment of risk stratification scores in real time within electronic health records (EHRs) would overcome a major impediment. This requires an automated mechanism to accurately identify ("phenotype") patients with GIB at the time of presentation. The goal is to identify patients with acute GIB by developing and evaluating EHR-based phenotyping algorithms for emergency department (ED) patients. MethodsWe specified criteria using structured data elements to create rules for identifying patients, and also developed a natural-language-processing (NLP)-based algorithm for automated phenotyping of patients, tested them with tenfold cross-validation (n=7144) and external validation (n=2988), and compared them with the standard method for encoding patient conditions in the EHR, Systematized Nomenclature of Medicine (SNOMED). The gold standard for GIB diagnosis was independent dual manual review of medical records. The primary outcome was positive predictive value (PPV). ResultsA decision rule using GIB-specific terms from ED triage and from ED review-of-systems assessment performed better than SNOMED on internal validation (PPV=91% [90%-93%] vs. 74% [71%-76%], P<0.001) and external validation (PPV=85% [84%-87%] vs. 69% [67%-71%], P<0.001). The NLP algorithm (external validation PPV=80% [79-82%]) was not superior to the structured-datafields decision rule. ConclusionsAn automated decision rule employing GIB-specific triage and review-of-systems terms can be used to trigger EHR-based deployment of risk stratification models to guide clinical decision-making in real time for patients with acute GIB presenting to the ED.

Background and study aimsColonic diverticular bleeding (CDB) is a common cause of lower gastrointestinal bleeding, and rebleeding remains a significant clinical challenge despite various hemostatic techniques. Clipping and endoscopic band ligation are commonly performed; however, the efficacy of endoscopic coagulation with clipping (ECC) remains unclear. This study aimed to evaluate the efficacy and safety of ECC in treating CDB. Patients and methodsWe retrospectively analyzed 217 patients with suspected CDB seen at our institution between January 2017 and December 2024. Clinical outcomes, such as rebleeding rates within 30 days, adverse events, and length of hospital stay were assessed. ECC was defined as thermal coagulation of the bleeding vessel within the diverticulum, followed by closure with clips to reinforce hemostasis and prevent perforation. ResultsOf these, 202 patients underwent colonoscopic evaluation (15 were excluded due to spontaneous hemostasis or other reasons before endoscopy), 74 (36.6%) underwent ECC for hemostasis. Rebleeding occurred in 7 patients (9.5%) within 30 days. Diverticulitis with subsequent colonic perforation was observed in one patient (1.4%), who improved with conservative treatment, and exhibited no fatal adverse events. ConclusionsWith a favorable safety profile and low rebleeding rates, ECC can be a treatment option for CDB. Its simplicity and low reliance on specialized equipment make it a practical alternative to other hemostatic methods in clinical practice.

ObjectivePernicious anaemia (PA) is characterised by vitamin B12 deficiency due to autoimmune-mediated loss of gastric parietal cells and intrinsic factor. The Pernicious Anaemia Society (PAS) identified 10 research priorities for PA through a James-Lind Alliance Priority Setting Partnership (JLA-PSP). This study aimed to survey PAS members to identify and characterise a cohort of patients to form a PA research repository. MethodsAn online survey was designed using SurveyMonkey, comprising 21 questions on diagnosis, comorbidities, family history, and management. The survey was sent to 3,482 PAS members (April-September 2022) via the PAS website and email. ResultsA total of 1,191 PAS members completed the survey. Among individuals with a probable (n=471) or suspected PA (n=500) diagnosis, 84% were UK-based, and 81% were female, with an age range of 23-93 years. Diagnosis was predominantly based on low serum B12 (50%), positive intrinsic factor (38%), and/or parietal cell autoantibodies (15%). Diagnostic delays were common, with 37% waiting [&ge;]3 years for a diagnosis. Nearly half had one or more other autoimmune diseases. One-third reported having at least 2 and up to 7 family members with PA or other autoimmune diseases. Vitamin B12 treatment frequency varied widely, ranging from daily to 3-monthly injections. ConclusionThis study highlights gaps in current diagnostic and management approaches for PA, paving the way for future work in line with the JLA-PSP research priorities. By characterising a cohort of PA patients and compiling baseline data, we provide a foundation for research to develop more effective diagnostic and management strategies.

BackgroundChronic gastroduodenal disorders including chronic nausea and vomiting syndrome, gastroparesis, and functional dyspepsia, are challenging to diagnose and manage. The diagnostic and treatment pathways for these disorders are complex, costly and overlap substantially; however, experiences of this pathway have not been thoroughly investigated. This study therefore aimed to explore clinician and patient perspectives on the current clinical pathway. MethodsSemi-structured interviews were conducted between June 2020 and June 2022 with 11 patients with chronic nausea and vomiting syndrome alone or with functional dyspepsia (based on Rome IV criteria) and nine gastroenterologists who treat these conditions. Interviews were recorded, transcribed, and thematically analyzed using an iterative, inductive approach. ResultsFive key patient themes were identified: (1) the impacts of their chronic gastroduodenal symptoms, (2) the complexity of the clinical journey, (3) their interactions with healthcare providers, (4) the need for advocacy, and (5) their experience of treatments. Five key clinician themes were also identified: (1) these conditions were seen as clinically complex, (2) there is an uncertain and variable clinical pathway, (3) the nuance of investigations, (4) these conditions were difficult to therapeutically manage, and (5) there are barriers to developing a therapeutic relationship. ConclusionsFindings indicate that both patients and clinicians are dissatisfied with the current clinical care pathways for nausea and vomiting syndromes and functional dyspepsia. Recommendations included the development of more clinically relevant and discriminant tests, standardization of the diagnostic journey, and the adoption of a multidisciplinary approach to diagnosis and treatment.

BackgroundInflammatory bowel disease (IBD) manifests systemically, yet most comorbidity studies rely on predominantly European populations. The All of Us Research Program enables investigation across demographically diverse groups. MethodsWe matched 5,094 IBD patients 1:4 with controls by age, gender, and race, analyzing comorbidities using logistic regression with Mantel-Haenszel adjustment. Multiple testing correction used false discovery rate (FDR) with significance thresholds of OR >1.5 or <0.5 and FDR <0.05. ResultsOur cohort included 29.2% non-White participants versus 10-15% in traditional studies. We identified 22 significant associations across seven organ systems. Three novel discoveries included delayed postmyocardial infarction pericarditis (adjusted OR = 4.80), contact dermatitis (adjusted OR = 1.84), and carotid artery aneurysm (adjusted OR = 2.21). Other significant associations included drug-induced lupus (adjusted OR = 4.32), autoimmune hepatitis (adjusted OR = 2.43), and restricting-type eating disorders (adjusted OR = 4.00). IBD patients showed decreased obesity-related conditions. ConclusionThis demographically diverse study discovered novel IBD comorbidities and confirmed established associations across racial groups. Findings support reconceptualizing IBD as a multisystem disorder requiring comprehensive management and demonstrate the importance of diverse research populations.

ImportanceA precision medicine approach to identify who would benefit from supplementation with the n-3 highly unsaturated fatty acid (HUFA) eicosapentaenoic acid (EPA) for colorectal cancer prevention has not been reported. A fatty acid desaturase 2 (FADS2) insertion-deletion (Indel) polymorphism (rs66698963) controls levels of the n-6 HUFA arachidonic acid (AA), which drives intestinal tumorigenesis and which is antagonized by EPA. ObjectiveWe tested the hypothesis that the FADS2 Insertion (I) allele, which is associated with elevated AA levels, predicts those individuals who display colorectal polyp risk reduction by EPA. DesignSecondary analysis of the randomized, placebo-controlled, 2x2 factorial seAFOod polyp prevention trial of EPA 2g daily and aspirin 300mg daily, stratified for FADS2 Indel genotype. SettingColonoscopy surveillance 12 months after clearance screening colonoscopy, in the English Bowel Cancer Screening Programme (BCSP). ParticipantsA predominantly White European, male cohort (mirroring the BCSP colonoscopy demographic). 528 trial participants with colonoscopy data and a FADS2 Indel genotype from the original randomized trial population of n=707. Main Outcome(s) and Measure(s)Total (adenomatous and serrated) colorectal polyp risk associated with EPA or aspirin compared with its respective placebo. Presence of at least one I allele and an interaction term (at least one I allele x active intervention) were co-variates in negative binomial regression models. ResultsEPA use, irrespective of FADS2 Indel genotype, was not associated with reduced total colorectal polyp number (incidence rate ratio [IRR] 0.92, 95% confidence interval 0.74,1.16), mirroring the original seAFOod trial analysis. However, the presence of at least one I allele identified EPA users with a significant reduction in colorectal polyp number (IRR 0.50 [0.28, 0.90]), unlike aspirin for which there was no evidence of an interaction. Similar findings were obtained for analysis of the polyp detection rate (% of individuals with at least one polyp). Conclusions and RelevanceThe FADS2 Indel I allele identifies individuals who display colorectal polyp prevention efficacy of EPA, with a similar effect size to aspirin. Assessment of rs66698963 as a therapeutic response biomarker in other populations and healthcare settings is warranted. Trial RegistrationThe seAFOod polyp prevention trial and STOP-ADENOMA project - ISRCTN05926847. Key pointsO_ST_ABSQuestionC_ST_ABSDoes a functional fatty acid desaturase 2 (FADS2) insertion-deletion (Indel) polymorphism (rs66698963) predict colorectal polyp prevention efficacy of eicosapentaenoic acid (EPA)? FindingsIn 528 participants of the 2 x 2 factorial seAFOod polyp prevention trial of the n-3 highly unsaturated fatty acid (HUFA) EPA and aspirin, who had both colonoscopy outcome and Indel genotype data, a gene (I allele carrier) x treatment interaction identified individuals for whom EPA significantly reduced colorectal polyp number by approximately 50% (a similar effect size to aspirin). MeaningFurther evaluation of a precision medicine approach using the FADS2 Indel polymorphism rs66698963 as a therapeutic response biomarker for cancer and cardiovascular disease prevention by n-3 HUFAs is warranted.