Gastroenterology

Metastatic pancreatic ductal adenocarcinoma (PDAC) remains deadly, with minimal improvement in prognosis over the past 20 years despite expansion of our chemotherapeutic arsenal. The complex tumor microenvironment (TME) of PDAC in the advanced stage, which often accompany clinical diagnosis, likely contributes to the limited efficacy of current standard of care chemotherapy. Informed by mechanistic preclinical studies, we evaluated the impact of inhibition of Hedgehog (Hh) signaling to prime PDAC TME and leverage anti-tumor efficacy of Gemcitabine plus nab-Paclitaxel (GnP) together with anti-CTLA-4 immune check point inhibitor (ICI, zalifrelimab). Hh inhibition using NLM-001 (an oral small molecule inhibitor of Smo) aimed to polarize the PDAC TME, including cancer associated fibroblasts (CAFs) and intratumoral immune profile, and to foster an immunosuppressive milieu that engages ICI. In this Phase 1b/2, open label, single arm study, patients with metastatic PDAC received standard GnP every 28-day cycles. In addition, NLM-001 was given at 800 mg daily on days -4 to -1 and days 10 to 13 of the GnP cycles 1 to 3, 6 to 8, 11 to 13 onwards (3 cycles on, followed by 2 rest cycles). Anti CTLA-4 inhibitor, zalifrelimab, was administered at 1mg/kg on day 15 of cycle 1 and every 6 weeks thereafter. The primary end point was to assess efficacy by objective response rate (ORR) as per RECIST v1.1. Treatment was overall well tolerated in the 28 patients enrolled. Most frequent grade 3-4 adverse events (AEs) were neutropenia (46.4%), asthenia (21.4%), and neurotoxicity (14.3%). No patient discontinued treatment due to toxicity. ORR was 50% [95% CI, 29.1-70.9] and disease control rate was 95.5% [95% CI, 86.8 - 100.0]. Median progression-free survival (PFS) was 7.3 months 95.5% [95% CI, 5.564 - 9.041] and median overall survival (OS) was 11.5 months [95% CI, 10.23 -12.73]; 1-year PFS was 18.2% [95% CI, 2.1 - 34.3] and 1-year OS was 50% [95% CI, 29.0 - 710]. Patients who achieved ctDNA clearance at cycle 4 had a significant better PFS (10.7 vs 6.0 months; p<0.0001). Paired biopsies immunolabeling and spatial transcriptomic analyses showed polarization of the TME, with increased CD4+ and CD8+ T cells infiltration, down trending Tregs, and decreased SMA/FAP ratio. Hedgehog inhibitor NLM-001 in combination with gemcitabine/nab-paclitaxel and zalifrelimab was safe and well tolerated and showed encouraging objective responses in the first line treatment of advanced PDAC. Clinical Trial RegistrationEudraCT: 2020-004932-52; NCT04827953.

BackgroundEndoscopic resection is the standard treatment for rectal neuroendocrine tumors (r-NETs) [&le;]10 mm, yet the optimal technique remains controversial. Modified endoscopic mucosal resection (m-EMR) has emerged as a potential alternative compared to endoscopic submucosal dissection (ESD), but existing evidence is largely retrospective and the results of recent randomized controlled trials (RCTs) are inconclusive. AimsTo compare the efficacy and safety of m-EMR versus ESD for r-NETs [&le;]10 mm. MethodsWe systematically searched CENTRAL, PubMed, Embase, and WanFang from January 1st, 1970 to December 23, 2025 for RCTs comparing m-EMR with ESD in r-NETs [&le;]10 mm. The GRADE framework assessed evidence certainty, while trial sequential analysis (TSA) controlled random errors and evaluated conclusion validity. ResultsSix RCTs involving 440 patients were analyzed. No significant difference between m-EMR and ESD was found in histologic complete resection (RR = 1.00, 95% CI 0.97-1.03; I2 = 0%), en bloc resection rates (P = 0.75) and procedure-related complications (P = 0.94). And m-EMR was associated with a significantly shorter procedure time (P<0.00001) and lower hospitalization cost (P<0.00001). The evidence was of moderate certainty; TSA confirmed its reliability, and both cumulative and sensitivity analyses supported the robustness. ConclusionsModerate-certainty evidence indicates m-EMR achieves oncologic outcomes comparable to ESD while offering clear advantages in procedural efficiency and cost for r-NETs [&le;]10 mm, supporting m-EMR possibly as a preferred endoscopic strategy in clinical practice.

BackgroundPatients with cirrhosis are highly susceptible to infections due to immune dysfunction and gut barrier impairment. Non-bloodstream infections frequently trigger decompensation and mortality, yet the global distribution of antimicrobial resistance (AMR) in these infections is poorly characterized. MethodsWe performed a systematic review and meta-analysis of studies reporting AMR in non-bloodstream bacterial infections among patients with cirrhosis. PubMed, Embase, and Web of Science were searched up to 15 September 2025. Pooled prevalence estimates of multidrug-resistant (MDR) and key resistant pathogens were calculated using random-effects models. Subgroup analyses were performed by country income, continent, and bacterial species. ResultsThirty-one studies including 3,162 infections were analysed. Spontaneous bacterial peritonitis predominated (79%), followed by colonisation (12%) and urinary tract infections (7%). Gram-negative bacteria accounted for 60% of infections (Escherichia coli 29%, Klebsiella pneumoniae 11%), while Gram-positive pathogens represented 39% (Enterococcus spp. 14%, Staphylococcus aureus 6%). Overall pooled MDR prevalence was 29%, with higher burdens in lower-middle-income countries (MDR 47% vs. 22-41%; ESBL 24% vs. 10%; VRE 21% vs. 3%; CRE 32% vs. 1%). Genotypic data identified 436 resistance genes with marked continental differences. ConclusionCirrhosis-associated non-bloodstream infections are dominated by Gram-negative bacteria and show high MDR, particularly in lower-middle-income countries. These findings highlight the need for integrated phenotypic and genomic surveillance of resistance patterns in these settings to guide empiric therapy.

PurposeHirschsprung-associated enterocolitis remains a major postoperative complication of Hirschsprungs disease (HD), and impaired epithelial barrier integrity has been proposed as a contributing factor. In this study, we investigated whether 12-hydroxyheptadecatrienoic acid (12-HHT), an endogenous leukotriene B4 receptor 2 (BLT-2) agonist, enhances the epithelial barrier and exerts anti-inflammatory effects in patient-derived colonic organoids. MethodsNormoganglionic specimens from rectal/rectosigmoid HD at pull-through (HD-N; n = 8) and transverse colon specimens from anorectal malformation (ARM) at colostomy closure (n = 10) were used to generate colonic organoids. Epithelia were isolated using ethylenediaminetetraacetic acid and subsequently embedded in Matrigel. Baseline expression of TJP1, TJP2, F11R (encoding junctional adhesion molecule-A), JAM2, CLDN1, CLDN3, CLDN4) and LTB4R2 (encoding BLT-2) was assessed by qPCR and immunoblotting. Organoids were then treated with 12-HHT (0.4, 2, or 10 M) for 7 days, followed by qPCR. Additional experiments assessed cytokine expression (IL1B, IL6) and TJPs after 24 h with tumor necrosis factor- (TNF-, 100 ng/mL) plus phosphate buffered saline or 12-HHT. Barrier function was evaluated using FITC-dextran influx assays. ResultsHD-N and ARM organoids exhibited similar growth efficiencies. Baseline expression for F11R, JAM2, CLDN1, CLDN3, CLDN4, and LTB4R2 was significantly lower in HD-N than in ARM. TJPs were upregulated by 12-HHT at 2 and 10 M in both groups, with stronger effects in ARM. In HD-N organoids, 10 M 12-HHT suppressed TNF--induced IL1B and IL6 elevation mitigated tight junction proteins (TJPs) downregulation more effectively than 2 M. 12-HHT attenuated TNF--induced FITC-dextran influx in HD-N organoids. Conclusion12-HHT may exert anti-inflammatory effects by integrating TJPs of HD-N.

Introduction Vonoprazan, 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. Methods Following 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. Results Three 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 years. There was no significant difference in rebleeding rates between patients receiving PPIs and PCABs (RR 0.827; 95 % CI: 0.5 to 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 to -0.17), but no significant difference in all-cause mortality between both groups (RR: 0.90, 95% CI: 0.79 to 1.04). Conclusions Our 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. Keywords: Vonoprazan, Proton Pump inhibitors, peptic ulcer bleeding, Endoscopy

BackgroundPerianal Crohns disease (PCD) represents one of the most severe and refractory forms of pediatric inflammatory bowel disease (IBD). Constipation and colonic redundancy, particularly type 1 dolichocolon (T1-DC), may increase distal rectosigmoid pressure, and exacerbate perianal pathology. We hypothesized that T1-DC is more common in children with PCD than in those with uncomplicated ileocolonic Crohns disease (CD) or non-IBD controls. MethodsWe retrospectively analyzed 20 consecutive pediatric PCD cases (penetrating [B3p] or inflammatory [B1p]) and compared them with 20 patients with non-complicated ileocolonic CD (L3/B1) and 30 non-IBD trauma controls. DC type was determined radiographically using established criteria, focusing on T1- and T2-DC. Constipation history was abstracted from medical records under IRB-approved protocols. ResultsDC was significantly more prevalent in PCD than in ileocolonic CD or controls (p < 0.001), primarily due to T1-DC. The associations persisted (p<0.03) in PCD patients without a history of constipation. ConclusionsRectosigmoid redundancy (T1-DC) may represent an underrecognized anatomic co-morbidity in pediatric PCD, contributing to increased distal pressure and susceptibility to perianal complications. Identification of T1-DC could inform surgical decision-making and postoperative management. Targeted approaches--such as segmental resection during stoma reversal, structured bowel regimens, physical activity, and pelvic-floor biofeedback--may help reduce recurrence risk. Prospective studies are needed to define the mechanistic role of colonic redundancy in the pathogenesis of PCD.

ObjectiveTo identify independent risk factors for early ([&le;]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 [&le;]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.

ObjectivesGastric cancer (GC) is a leading cause of cancer mortality in the United States (U.S.), yet no routine screening strategy exists. Opportunistic upper endoscopy (EGD) performed during screening colonoscopy (EGD-SC) may provide a practical early detection approach. We evaluated the feasibility, acceptability, patient perspectives, and diagnostic yield of EGD-SC. MethodsThis single-center, open-label, single-arm prospective trial enrolled adults aged 45-80 years scheduled for colonoscopy without prior EGD in the past five years. Feasibility was assessed by enrollment, added procedural time, and safety. Acceptability, patient beliefs, motivators, barriers, and satisfaction were assessed using pre- and post-procedure surveys. Gastric biopsies evaluated for precancerous lesions. ResultsOf individuals contacted, 51.6% expressed interest and 26.6% enrolled (n=50; median age 56; 48% male; 68% high-risk). Median added time was 17 minutes (range 9-26), with no complications. All participants rated EGD-SC as satisfactory (100%) and 90% as acceptable; most preferred the combined procedure (97.5%) and would recommend it to family or friends (92.5%). Knowledge gaps were common: nearly half lacked awareness of GC risk factors; although 72% viewed screening as beneficial, only 23.3% perceived GC as severe, and none considered themselves highly susceptible. EGD found H. pylori infection (32%), atrophic gastritis (14%), and intestinal metaplasia (12%), with higher prevalence among high-risk participants. ConclusionsEGD-SC is feasible, safe, and highly acceptable, with strong patient endorsement and meaningful detection of GC precursor lesions. These findings support risk-stratified EGD-SC as a promising and pragmatic strategy for GC prevention and early detection in the U.S.

Hereditary -tryptasemia (HT), defined by increased TPSAB1 copy number and elevated basal serum tryptase, is associated with mast cell (MC)-mediated symptoms, yet its role in gastrointestinal disease remains unclear. Because intestinal MCs express the non-IgE-dependent activation receptor MRGPRX2, we investigated whether MRGPRX2 expression is altered in individuals with HT and inflammatory bowel disease (IBD). We genotyped 854 biobanked IBD samples, performed spatial transcriptomics on descending colon tissue (n = 4 HT; n = 4 non-HT), and analyzed small-intestinal biopsies by mass cytometry (CyTOF; n = 5 HT; n = 9 controls). Across these complementary platforms, HT was associated with increased gastrointestinal MC abundance and higher expression of activation markers including CD203c, LAMP-1, and SIGLEC8. Both spatial transcriptomics and ddPCR demonstrated significantly increased MRGPRX2 and SIGLEC8 transcripts in IBD samples from individuals with HT compared with matched non-HT IBD cases. These findings suggest that enhanced MRGPRX2 expression and associated MC activation may contribute to gastrointestinal symptoms in HT, particularly in the context of IBD. As interest in precision immunogenetics grows, defining MC phenotypes linked to -tryptase copy number may help refine diagnostic evaluation and identify patients who could benefit from emerging mast cell-targeted therapeutic strategies in the context of IBD.

BackgroundMetabolic dysfunction-associated steatohepatitis (MASH) is a prevalent and progressive liver disease with limited pharmacologic treatment options. Pemvidutide, a GLP-1-glucagon dual receptor agonist, has shown promise in targeting both hepatic steatosis and fibrosis. This systematic review and meta-analysis aimed to evaluate the efficacy and safety of pemvidutide in adults with MASH. MethodsWe systematically searched PubMed, Scopus, Web of Science, and Cochrane CENTRAL through December 15, 2025, for randomized controlled trials (RCTs) comparing once-weekly subcutaneous pemvidutide (1.2 mg, 1.8 mg, or 2.4 mg) with placebo in adult MASH patients. Primary outcomes were changes in liver fat content (LFC, % via MRI-PDFF) and Enhanced Liver Fibrosis (ELF) score. Secondary outcomes included body weight, glycemic and lipid parameters, blood pressure, heart rate, and adverse gastrointestinal events. Dose-specific pairwise meta-analyses were performed using a random-effects model. ResultsThree RCTs encompassing 370 participants (195 pemvidutide, 175 placebo) were included. Pemvidutide significantly reduced LFC at all doses, with the greatest effect at 1.8 mg (MD = -21.63%, 95% CI: -27.23 to -16.02; p<0.0001). ELF score improvement was significant at 1.2 mg and 1.8 mg doses but not at 2.4 mg. Across all doses, body weight decreased significantly, while HbA1c remained unchanged. Pemvidutide also reduced systolic blood pressure and total cholesterol (1.8 mg and 2.4 mg), with modest HDL reduction at 2.4 mg. Mild-to-moderate gastrointestinal adverse events were observed, with nausea more frequent at 1.8 mg. ConclusionsPemvidutide is effective in reducing liver fat and improving cardiometabolic parameters in MASH, with a favorable safety profile. Dose-specific effects on fibrosis suggest potential early antifibrotic activity, highlighting its promise as a dual-targeted therapy for MASH. Further long-term studies are warranted to confirm sustained hepatic and metabolic benefits.

BackgroundSystemic infections are a leading cause of hospitalization and death among patients with cirrhosis. Timely and accurate infection identification is essential for both clinical care and the development of predictive models. However, existing methods such as ICD-10 coding are unreliable, and manual chart review is resource-intensive and difficult to scale. This study aimed to develop and validate an automated large language model (LLM)-based approach for infection classification and subtyping in patients with cirrhosis presenting to the emergency department (ED). MethodWe developed INFEHR (INfection identification and subtyping using Free-text EHR analysis), an LLM-powered pipeline utilizing Claude 3.5 Sonnet to analyze clinical notes from the first 72 hours of admission. Model outputs were compared against a physician-adjudicated gold standard in a cohort of 1,000 encounters from patients with cirrhosis who presented to the ED. Performance was benchmarked against ICD-10 code-based labeling and CDC Adult Sepsis Event criteria. ResultsINFEHR achieved 94.7% overall accuracy, with 99.5% sensitivity and 92.8% positive predictive value for identifying infection presence, outperforming ICD-10-based classification across all metrics (p < 0.0001). The model also demonstrated strong performance in classifying pathogen type and infection site. This pipeline processed notes within seconds, offering improvements in efficiency and scalability over manual review. ConclusionINFEHR offers a scalable, reproducible, and accurate method for infection phenotyping in cirrhosis. By overcoming limitations of traditional coding and manual review, it supports high-throughput infection surveillance, improves cohort construction for clinical research, and enables future integration into real-time decision-support tools in hepatology.

Background and AimThe optimal second-line therapy following first-line atezolizumab plus bevacizumab (Atezo/Beva) remains unascertained. This study compared second-line durvalumab plus tremelimumab (Dur/Tre) with lenvatinib (Len) after first-line Atezo/Beva in unresectable hepatocellular carcinoma (uHCC). MethodsThis prospectively registered cohort study analyzed patients with uHCC who received Dur/Tre (n = 14) or Len (n = 67) as second-line therapy after first-line Atezo/Beva. Tumor response was assessed by RECIST version 1.1. Progression-free survival (PFS), overall survival (OS), adverse events (AEs), and changes in the albumin-bilirubin (ALBI) score were compared. ResultsThe objective response rate and disease control rate were 7.7% and 15.4% in the Dur/Tre group, and 23.3% and 76.7% in the Len group, respectively; median PFS was 1.7 vs. 4.2 months (p < 0.001) and median OS was 5.3 vs. 14.0 months (p = 0.047) in the Dur/Tre and Len groups, both significantly favoring Len. Multivariable analysis showed that Len treatment and neutrophil-to-lymphocyte ratio [&ge;]3 were independent predictors of longer PFS and worse OS, respectively. Grade [&ge;]3 AEs were more frequent with Len than with Dur/Tre (70.1% vs. 21.4%; p = 0.002). At week 4, the ALBI score did not worsen with Dur/Tre (-2.30 to -2.21; p = 0.318) but worsened with Len (-2.36 to -1.97; p < 0.001). ConclusionsAfter first-line Atezo/Beva, second-line Len achieved superior disease control and longer survival than Dur/Tre. However, grade [&ge;] 3 AEs were more frequent with Len than with Dur/Tre, and careful management of AEs is essential when choosing therapy for individual patients.

Chronic constipation is highly prevalent, and cases refractory to treatment are particularly challenging to manage. High-resolution colonic manometry (HRM) is used to further evaluate these patients to identify cases of intrinsic motor dysfunction (underlying myopathy or neuropathy). However, HRM is invasive and resource-intensive, limiting uptake and clinical utility. This study presents Body Surface Colonic Mapping (BSCM), a non-invasive cutaneous electrical recording technique, as a clinical alternative. Simultaneous recordings from HRM (36-channel) and BSCM (8x8 electrode array) were performed in 10 patients with chronic refractory constipation. Lower gut symptom scores were also tracked patients over the duration of the recording. Motility was assessed during meal and bisacodyl challenges. We optimized BSCM signal processing specifically to detect high-amplitude propagating contractions (HAPCs) evoked by bisacodyl. Analysis included time-frequency quantification of motility indices and blinded visual assessment by domain experts to classify the presence or absence of motor responses. BSCM motility indices showed strong correlation with HRM for both meal (r = 0.86) and bisacodyl (r = 0.69) responses. Expert visual analysis yielded concordant classification between BSCM and HRM in the majority (87.5 {+/-} 9.6%) of cases. Furthermore, BSCM identified distinct, patient-specific symptom-motility associations during the meal response. BSCM accurately detects meal- and stimulant-induced increases in colonic motility with high fidelity to invasive HRM. As a non-invasive method that is easy to apply with minimal resource and time requirements, BSCM is well-positioned for clinical translation as a scalable diagnostic tool to elucidate symptom-motility associations and guide personalized management in refractory chronic constipation.

BackgroundColorectal cancer (CRC) exhibits marked heterogeneity across age, ancestry, and treatment context, underscored by the rising incidence of early-onset disease (EOCRC). The mitogen-activated protein kinase (MAPK) signaling axis is a central regulator of CRC biology and treatment response, yet the frequency, distribution, and prognostic relevance of MAPK pathway alterations across demographically and clinically defined subgroups remain unclear. MethodsWe analyzed 2,515 CRC tumors with harmonized clinical, genomic, and treatment metadata. Patients were stratified by ancestry (H/L vs. non-Hispanic White [NHW]), age at diagnosis (early-onset vs. late-onset), and FOLFOX chemotherapy exposure. Somatic MAPK alterations were identified using a curated gene set spanning canonical and regulatory components of EGFR-RAS-RAF-MEK-ERK signaling. Conversational artificial intelligence (AI-HOPE and AI-HOPE-MAPK) enabled cohort construction and exploratory analytics using natural language queries, with all findings validated using standard statistical methods. Overall survival (OS) associations were evaluated using Kaplan-Meier analyses. ResultsMAPK pathway alterations demonstrated marked heterogeneity across ancestry and treatment contexts. Among EO H/L patients, FGFR3, NF1, and RPS6KA6 mutations were significantly more frequent in those not treated with FOLFOX, while PDGFRB alterations were enriched in EO H/L patients receiving FOLFOX compared with EO NHW counterparts. In late-onset H/L disease, NTRK2 and PDGFRB mutations were more prevalent in non-FOLFOX-treated tumors. Distinct MAPK-related alterations were also observed among NHW patients, including enrichment of AKT3, FGF4, RRAS2, CRKL, DUSP4, JUN, MAPK1, RRAS, and SOS1 mutations in non-FOLFOX-treated groups, as well as age-dependent differences in BRAF and TP53 mutation frequencies. Survival analyses revealed borderline evidence that MAPK pathway alterations were associated with improved overall survival in select NHW subgroups, including EOCRC patients treated with FOLFOX. Conversational AI enabled rapid generation and validation of multi-parameter queries. ConclusionsAlthough MAPK pathway disruption is a near-universal molecular feature in CRC, the specific genes, effectors, and regulatory nodes altered vary by ancestry, age of onset, and chemotherapy exposure, revealing biologically and clinically meaningful substructure that is not captured by pathway-level status. NF1, MAPK3, RPS6KA4, and PDGFRB emerge as candidate genomic biomarkers in EOCRC and in H/L populations, while BRAF and adaptor-mediated signaling alterations are enriched in late-onset CRC. Conversational AI significantly accelerated analytic throughput and supported equity-driven biomarker discovery. Future studies incorporating multi-omic data and diverse prospective cohorts will be essential to refine MAPK-based precision strategies and address population-level disproportions in CRC.

The incidence of early-onset colorectal cancer (EOCRC; <50 years) is rising rapidly among populations. Although alterations in the RTK-RAS signaling pathway are central to colorectal cancer (CRC) progression, their prognostic significance in FOLFOX-treated EOCRC remains poorly defined. We analyzed 2,515 CRC cases (H/L = 266; non-Hispanic White [NHW] = 2,249) stratified by ancestry, age at onset, and FOLFOX treatment status using Fishers exact, chi-square, and Kaplan-Meier survival analyses. We further employed the AI-HOPE and AI-HOPE-RTK-RAS conversational artificial intelligence platforms to integrate clinical, genomic, and treatment-level data through multi-parameter, natural language-driven queries. Among EO H/L patients, ERBB2 (2.7% vs. 15.4%, p = 0.01) and NF1 (4.1% vs. 19.2%, p = 0.01) mutations were significantly less frequent in FOLFOX-treated compared with untreated patients. Among LO H/L patients, NTRK2 mutations were less enriched in FOLFOX-treated cases (0.0% vs. 6.0%, p = 0.04). In FOLFOX-untreated EO H/L patients, MAPK3 (5.8% vs. 1.0% in EO NHW; p = 0.04) and NF1 (19.2% vs. 6.0% in LO NHW; p = 0.002) mutations were significantly enriched. Among EO NHW patients, IGF1R (2.1% vs. 5.3%, p = 0.04) and ERRFI1 (0.5% vs. 2.6%, p= 0.02) mutations were less frequent in FOLFOX-treated versus untreated cases. In LO NHW patients, multiple RTK-RAS genes (ERBB3, KIT, IGF1R, RET, ALK, FLT3, ERRFI1, ARAF, RAF1) were less enriched with FOLFOX exposure. Survival analyses revealed that RTK-RAS pathway alterations predicted worse overall survival in FOLFOX-untreated EO NHW patients (p = 0.029) but were associated with improved survival in FOLFOX-treated LO NHW patients (p = 0.048). Collectively, these findings indicate that RTK-RAS pathway alterations exhibit strong ancestry-, age-, and treatment-specific effects and may serve as precision biomarkers of differential chemotherapy response. The AI-enabled framework markedly accelerated integrative biomarker discovery, supporting its utility for advancing precision oncology in populations affected by EOCRC.

BACKGROUNDEarly detection of colorectal cancer (CRC) is essential for reducing disease-related mortality; however, the invasiveness and resource intensity of colonoscopy limit its widespread use in population screening. Although several non-invasive screening modalities are available, their sensitivity remains suboptimal, particularly for advanced precancerous lesions (APL). Stool-derived host RNA biomarkers represent a promising approach to improve screening performance. However, numerous technical challenges are associated with extracting and quantifying this RNA, including an abundance of PCR inhibitors, a high microbial background, and varying levels of RNA degradation. METHODSWe developed an extraction method for the isolation of host RNA from stool with improved sensitivity of detection and better diagnostic performance than the conventional phenol-chloroform-based extraction. ECB-Extract (Enrichment Capture By hybridization), uses hybridization capture of RNA under denaturing conditions by adding locked nucleic acid bases to the probes. The improved hybridization characteristics allow us to directly isolate host RNA from stool lysate. RESULTSECB-Extract significantly improved PCR inhibitor removal, enabling scale-up of stool input and resulting in increased diagnostic sensitivity. We evaluated ECB-Extract against a conventional phenol-chloroform-based extraction method using the same panel of biomarkers in a pilot clinical cohort (N = 73). Using ECB-Extract, the sensitivity for detecting CRC and Advanced Precancerous Lesions (APL) was 96% and 50%, respectively, compared with 56% and 21% for the phenol-chloroform comparator at 96% specificity. In a larger cohort of 359 samples, ECB-Extract combined with a panel of the eight CRC-associated mRNA biomarkers achieved sensitivities of 95.7% for CRC and 51.2% for APL at a specificity greater than 90%. CONCLUSIONThese results demonstrate that ECB-Extract substantially improves stool host RNA extraction performance and, consequently, enhances diagnostic sensitivity for CRC and APL.

IntroductionPrevious studies have shown that Aquamin(R), a multi-mineral extract from red marine algae, enhances barrier integrity proteins in the human colon. These findings prompted further investigation into Aquamin(R)s effects on gastrointestinal barrier function and permeability. MethodsSubjects with mild or in remission ulcerative colitis (UC) and healthy controls were enrolled in an open-label trial and received Aquamin(R) capsules (800 mg calcium/day) for 90 days. Intestinal permeability was evaluated before and after the 90-day intervention by urinary mannitol excretion after ingestion of a 5 g mannitol solution, with collections across several time intervals (pre-drink, 0-2 h, 2-8 h, and 8-24 h). The primary outcome was the change in mannitol excretion. Serum samples were also collected to assess liver and renal function. ResultsIn this pilot study (NCT04855799), which included UC patients and healthy controls (n = 8 per group), baseline urine mannitol levels in the 0-2 h sample were 54% higher in UC patients compared to healthy subjects (p = 0.006). Following 90 days of Aquamin(R) supplementation, urinary mannitol levels in UC patients decreased by 28%, 26%, and 41% at the 0-2 h, 2-8 h, and 8-24 h timepoints, respectively; the reduction at the 0-2 h interval reached statistical significance (p = 0.015). Overall, Aquamin(R) supplementation reduced total post-intervention mannitol excretion by 29% (p = 0.024). Aquamin(R) was well tolerated, with no serious adverse events reported. The serum metabolic panel revealed a modest but statistically significant reduction in alkaline phosphatase levels after 90 days of intervention. ConclusionThese results provide preliminary evidence that Aquamin(R) supplementation beneficially modulates gut barrier function and supports epithelial integrity in UC patients. These findings support further investigation of Aquamin(R) as a safe and promising adjunct to current UC management strategies, with potential utility as a barrier therapy in UC. SummaryAquamin(R) supplementation for 90 days reduced intestinal permeability in ulcerative colitis patients, as measured by urinary mannitol excretion. The intervention was well tolerated, suggesting Aquamin(R) may be a safe, promising adjunct for enhancing gut barrier function in UC management.

BackgroundCurrent British Society of Gastroenterology (BSG) guidelines misclassify metachronous lesion risk after polypectomy in approximately 40% of patients. Building on evidence that immune exclusion drives progression of adenomas to colorectal cancer, this study examined immune profiles in screen-detected adenomas as a predictive biomarker for metachronous lesion risk. MethodsPatients undergoing polypectomy within the Scottish Bowel Screening Programme, with surveillance colonoscopy between 6 months and 6 years were included. Chromogenic immunohistochemistry (IHC; n=2642), 6-plex multiplex immunofluorescence (mIF; n=334), and spatially resolved 6000-plex single cell transcriptomics (n=7) were applied to adenoma microarrays. Cell density and location were measured using QuPath. Hierarchical then K-means clustering was used to define immune cell density-based clusters, which were compared to future lesion events using Kaplan-Meier curves and the log rank test. ResultsAfter adjustment for age, sex, site, size and dysplasia, adenoma CD3+ T cell density was significantly associated with future colorectal neoplasia (HR 1.43, 95% CI 1.19-1.71, p<0.001). Using mIF three immune cell density clusters were identified; 1) high T cell density, low macrophage density, 2) low T cell density, low macrophage density, and 3) high T cell, macrophage and SMA density, with significant differences in future lesion risk (Cluster 1: 22%, Cluster 2: 41%, Cluster 3: 36%, p=0.032). Bulk RNAseq and spatial transcriptomic analysis revealed significant variation in T cell and macrophage co-location and gene expression profiles between clusters. ConclusionAdenoma immune contexture emerges as a determinant of future metachronous lesion risk, offering a novel biomarker to refine surveillance and reduce disease burden. SummaryWhat is already known on this topic: O_LIPost-polypectomy surveillance is currently recommended to patients with high-risk pathological features to detect metachronous lesions and cancer. However current guidelines misclassify risk in a proportion of patients, leading to unnecessary surveillance for some, whilst falsely reassuring others. C_LI What this study adds: O_LIAnalysis of this large post-polypectomy surveillance cohort reveals that adaptive immune responses within removed index adenomas predicts low risk of metachronous lesions, while an immune excluded phenotype signals higher risk, independent of pathological characteristics, and patient risk factors. C_LI How this study might affect research, practice or policy: O_LIDefining immune cell spatial distributions and interactions that drive future adenoma and cancer risk will enable more precise risk stratification for surveillance, informing surveillance guidelines and shaping targeted colorectal cancer prevention strategies. C_LI

Background and aimsMolecular subtyping of pancreatic ductal adenocarcinoma (PDAC) into basal-like and classical has established prognostic and predictive value. However, its use in clinical practice is limited by cost, turnaround time, and tissue requirements, thereby restricting its application in the management of PDAC. We introduce PanSubNet (PANcreatic SUBtyping NETwork), an interpretable deep learning framework that predicts therapy-relevant molecular subtypes directly from standard hematoxylin and eosin (H&E)-stained whole-slide images. MethodsPanSubNet was developed using data from 1,055 patients across two multi-institutional cohorts (PANCAN, n=846; TCGA, n=209) with paired histology and RNA sequencing data. Ground-truth labels were derived using the validated Moffitt 50-gene signature refined by GATA6 expression. The model employs dual-scale architecture that fuses cellular-level morphology with tissue-level architecture, leveraging attention mechanisms for multi-scale representation learning and transparent feature attribution. ResultsOn internal validation within PANCAN using five-fold cross-validation, PanSubNet achieved mean area under the receiver operating characteristic curve (AUC) of 88.5% in high-confidence cases, with balanced sensitivity and specificity. External validation on the independent TCGA cohort without fine-tuning demonstrated robust generalizability (AUC 84.0%). PanSubNet preserved and, in metastatic disease, strengthened prognostic stratification compared to RNA-seq-based labels. Prediction uncertainty linked to intermediate transcriptional states, not classification noise. Model predictions are aligned with established transcriptomic programs, differentiation markers, and DNA damage repair signatures. ConclusionsBy enabling rapid, cost-effective molecular stratification from routine H&E-stained slides, PanSubNet offers a clinically deployable and interpretable tool for genetic subtyping. We are gathering data from two institutions to validate and assess real-world performance, supporting integration into digital pathology workflows and advancing precision oncology for PDAC.

BackgroundCrohns disease (CD) is a chronic inflammatory disorder of the gastrointestinal tract characterized by high post-operative recurrence (POR) rates, reaching up to 90% within one year. Current clinical and endoscopic predictors show limited accuracy. ObjectiveThis study aimed to identify molecular mechanisms associated with POR at the time of surgery through integrated transcriptomic and bacteriomic analyses of ileal tissue. DesignIleal samples were obtained during surgery from 20 patients with CD and 10 inflammatory bowel disease-free controls, with an independent validation cohort of 49 patients with CD. POR was evaluated every six months using ileocolonoscopy and defined by Rutgeerts score. Host gene expression and tissue-associated microbiome profiles were integrated using correlation and pathway enrichment analyses to uncover host-microbe interactions linked to POR. ResultsIn the inflamed mucosa of patients who developed endoscopic POR, we identified a novel immune interaction involving the Porphyromonadaceae family, mainly Parabacteroides gordonii, which was slightly depleted. This depletion was associated with downregulation of epithelial barrier and tissue repair genes, including TFF1 and LSR, findings confirmed in the validation cohort. Porphyromonadaceae abundance positively correlated with short-chain fatty acid levels, particularly propionate. Additionally, omics integration revealed an association between Xanthomonadaceae and increased expression of ITGAM, a gene involved in neutrophil activation. ConclusionThese results highlight microbial-host gene interactions associated with POR. The pathogenic ITGAM-driven immune signature and the protective Porphyromonadaceae-TFF1-propionate axis supporting epithelial integrity may enable microbiome-informed prognostic tools and therapeutic strategies for CD POR. O_LIWhat is already known on this topic: Post-operative recurrence in Crohns disease is linked to microbial dysbiosis, particularly reduced diversity and expansion of Enterobacteriaceae. However, how microbial changes translate into host molecular mechanisms driving POR remains unclear. C_LIO_LIWhat this study adds: This prospective multi-omic study identifies a disrupted Porphyromonadaceae-SCFA-epithelial barrier axis and the participation of neutrophil responses in patients who develop POR at surgery time. C_LIO_LIHow this study might affect research, practice or policy: The findings provide mechanistic targets for microbiome-informed risk stratification and prevention of POR. They support development of microbial or metabolite-based interventions aimed at restoring epithelial barrier function after surgery. C_LI