Annals of Gastroenterology

Endoscopic treatment modalities for the management of gastroparesis: a critical review

2025-08-04T19:24:45+03:00

Gastroparesis, a chronic condition with complex etiopathogenesis, is associated with considerable symptom burden and significant morbidity. Dietary modifications and pharmacotherapy exhibit limited long-term efficacy, while surgical interventions are characterized by higher morbidity and variable efficacy. Endoscopic procedures, because of their less invasive nature, have been the focus of past and ongoing research. The majority of endoscopic treatment modalities target the pylorus: e.g., gastric peroral endoscopic pyloromyotomy, botulinum toxin injection, pyloric balloon dilatation, and transpyloric stent placement. Endoscopic feeding tube placement,
endoscopic gastric electrical stimulation, and endoscopic ultrasound-guided gastroenterostomy have also been used to treat gastroparesis; however, these procedures are less well-studied. This critical review provides a detailed overview of the available endoscopic procedures for the management of gastroparesis, with emphasis on their pros and cons, quality of data and overall efficacy.

Keywords Gastroparesis, endoscopic treatment, G-POEM, Botox, stent

Ann Gastroenterol 2025; 38 (4): 353-363

Early-onset colorectal cancer in patients younger than 50 years: a systematic review of the literature

2025-08-04T19:24:45+03:00

Early-onset colorectal cancer (EO-CRC) refers to CRC diagnosed before the age of 50. Its incidence has risen in recent years, turning researchers’ attention to its oncologic behavior and potentially modifiable risk factors. In this review, PubMed/MEDLINE database was searched for all original research articles concerning EO-CRC. The inclusion criteria were CRC patients under 50, without a known predisposing factor for malignancy or an inherited CRC syndrome, presenting oncological characteristics and outcomes. All studies were assessed for bias, based on the ROBINS-E 2022 tool, and were synthesized in a qualitative analysis. Twenty-nine articles, reporting on 64,376 EO-CRC patients, were included in the qualitative synthesis. Results were classified into 3 categories: a) demographics; b) histopathologic characteristics; and c) treatment outcomes. Of these publications, 21 studies agreed that rectum (45%) and left-sided (47.1%) cancers are most common in younger patients, and 5 indicated that the highest prevalence of CRC concerns the 40-49 years age group. Seventeen of 29 studies reported a higher stage (III and IV) on diagnosis, with lymphovascular and perineural invasion. Our review has some limitations: as it was based on a single database, not all studies provided information on the variables; and patients were not categorized in all studies in the same age groups, although all were under 50 years. As EO-CRC is on the rise, the need for closer monitoring and possibly earlier screening becomes apparent. Further research should focus on finding novel screening biomarkers and modifiable risk factors that would decrease mortality and improve patient
outcomes.

Keywords Early-onset colorectal cancer, young adults, guidelines, 50 years old
Ann Gastroenterol 2025; 38 (4): 364-379

Understanding clinically significant portal hypertension: an in-depth look at pathogenesis, diagnosis and treatment

2025-08-04T19:24:45+03:00

The development of clinically significant portal hypertension (CSPH) represents one of the strongest predictive biomarkers for disease progression in patients with compensated advanced chronic liver disease (cACLD). Chronic liver injury triggers both intra- and extrahepatic mechanisms, giving rise to an increasing portal pressure and a self-perpetuating cycle with worsening risks of liver-related complications and mortality. Diagnosing CSPH becomes challenging in patients with advanced but compensated chronic liver disease where CSPH is not apparent clinically. Approximately 60% of patients with cACLD will have CSPH, representing a critical window for intervention to reduce portal pressure and prevent complications. The current gold standard for portal pressure measurement, the hepatic venous pressure gradient, is impractical for widespread use. Emerging diagnostic tools aim to address this limitation. Techniques such as endoscopic ultrasound-guided portal pressure gradient measurement, and noninvasive approaches using imaging methods, elastography (targeting liver and/or spleen) and serum markers, offer alternatives for CSPH detection, and moreover, can guide treatment decisions. Non-selective beta-blockers are known to reduce morbidity and mortality in patients with CSPH. Unfortunately, they remain the only approved therapy for CSPH and they are not effective in reducing portal pressure in all patients, highlighting the urgent need for additional therapeutic options as well as practical methods to evaluate treatment response. Recent innovations and ongoing research are steering the field toward a more personalized approach, where diagnosis, treatment and follow up are tailored to individual patient risk profiles. This evolution holds the potential to improve outcomes in patients with CSPH.

Keywords Portal hypertension, elastography, noninvasive test, beta-blockers
Ann Gastroenterol 2025; 38 (4): 380-391

Characteristics of early- versus late-onset esophageal adenocarcinoma: insights from the National Inpatient Sample 2016-2020

2025-08-04T19:24:45+03:00

Background The incidence of early-onset esophageal adenocarcinoma (EAC) in adults aged <50 years is rising, yet remains under-investigated. This study compared demographic, clinical and socioeconomic predictors of early- vs. late-onset EAC using national hospitalization data.

Methods We analyzed adult patients diagnosed with EAC from the National Inpatient Sample (2016-2020). Cases were stratified into early-onset (age <50 years) and late-onset (≥50 years), and further categorized by tumor location (upper, middle, lower esophagus). ICD-10-CM codes were used to identify diagnoses. Demographics, comorbidities and socioeconomic variables were compared using Rao-Scott chi-square tests.

Results Among 105,228 EAC admissions, early-onset cases comprised 5.89%. Lower esophagus involvement was most common (74.6%). Compared to late-onset patients, early-onset cases had a lower proportion of Caucasians (71.5% vs. 79.8%, P<0.001) and higher proportions of Black (13.9% vs. 9.6%) and Hispanic individuals (7.0% vs. 5.4%). Smoking (25.1% vs. 17.9%), obesity (11.4% vs. 8.4%), and drug use (28.9% vs. 19.7%) were more prevalent in early-onset patients (P<0.001). In contrast, late-onset patients had higher rates of hypertension (47.1% vs. 26.7%),
diabetes, chronic obstructive pulmonary disease and gastroesophageal reflex disease (P<0.001). Early-onset patients were less likely to be insured with Medicare (6.8% vs. 57.9%), and more likely with Medicaid (35.0% vs. 10.6%) or to be self-payers (3.9% vs. 1.8%).

Conclusions Early-onset EAC presents with distinct racial, socioeconomic and clinical profiles compared to late-onset disease. These findings underscore the need for tailored screening strategies and further research to address disparities and risk factors in younger populations.

Keywords Esophageal adenocarcinoma, early-onset, late-onset, National Inpatient Sample, risk factors

Ann Gastroenterol 2025; 38 (4): 392-400

Exploring the competencies of inflammatory bowel disease nurses in Italy: a cross-sectional survey

2025-08-04T19:24:46+03:00

Background Nurses are essential in the care of patients with inflammatory bowel disease (IBD). However, the competencies of IBD nurses in Italy still need to be studied. This research assessed Italian IBD nurses’ fundamental and advanced skills, providing a baseline for future professional development.

Methods This cross-sectional study used an online survey developed by a multidisciplinary expert panel, including gastroenterologists and IBD nurse specialists. The 53-item survey covered sociodemographics, professional characteristics, institutional context and competencies (fundamental and advanced), assessed via a 5-point Likert scale based on Nurse European Crohn and Colitis Organisation guidelines. Distributed nationwide from June to August 2024, descriptive statistics summarized participants’ profiles, while inferential analyses, including Pearson’s
correlations and ANOVA, explored associations between competencies and variables such as experience, education, and institutional factors.

Results The study analyzed responses from 50 IBD nurses, predominantly female (92%), with a mean age of 48.38±9.7 years. Fundamental competencies showed consistently higher mean scores compared to advanced competencies. High proficiency was noted in establishing empathetic relationships and recognizing the emotional impact of IBD (mean score: 4.06/5). Advanced competencies with the highest scores included caregiver education and multidisciplinary support (3.56/5 and 3.40/5, respectively). Significant correlations were observed between years of IBD-specific experience and competencies such as therapeutic management and stress handling.

Conclusions Italian IBD nurses demonstrate fundamental solid and moderate skills in advanced competencies. Enhancing educational programs and multidisciplinary collaboration can improve the quality of care for IBD patients. Future studies should address integrating digital health tools to support self-management and patient outcomes.

Keywords Inflammatory bowel disease, nurse, competence, multidisciplinary care team, nursing competency

Ann Gastroenterol 2025; 38 (4): 401-408

Oral vancomycin is associated with less therapy intensification in adults with symptomatic inflammatory bowel disease and underlying primary sclerosing cholangitis

2025-08-04T19:24:46+03:00

Background Case reports describe the use of oral vancomycin therapy (OVT) in adult patients with concomitant symptomatic inflammatory bowel disease (IBD) and primary sclerosing cholangitis (PSC). OVT is associated with a higher likelihood of IBD remission in pediatric IBDPSC patients. However, there are limited data on the association between OVT and IBD disease course in adult IBD-PSC patients.

Methods We retrospectively evaluated IBD therapy intensification in adults with IBD-PSC prescribed OVT at 2 centers. Subjects were stratified by time “on” and “off” OVT. Only those who spent a minimum of 12 months in each period were included. The primary outcome was the frequency of IBD therapy intensification events.

Results Of 31 patients initially considered, 22 met the inclusion criteria. Most patients (68.2%) had fewer or no intensification events while “on OVT” compared to those “off OVT”. OVT was associated with fewer therapy intensification events (1.7 vs. 6.7, P=0.021) and steroid prescriptions (0.6 vs. 3.2, P=0.013) per 10 person-years.

Conclusions OVT use is associated with less need for IBD therapy intensification in symptomatic IBD-PSC adult patients. Prospective trials of OVT in such patients are warranted.

Keywords Inflammatory bowel disease, primary sclerosing cholangitis, oral vancomycin therapy, disease activity

Ann Gastroenterol 2025; 38 (4): 409-414

Office-based flexible sigmoidoscopy allows rapid assessment and management of suspected immune checkpoint inhibitor-related colitis

2025-08-04T19:24:46+03:00

Background Immune checkpoint inhibitors (ICIs) have transformed cancer treatment but are frequently complicated by immune-related adverse events, including immunotherapy-related colitis (irColitis). Early and accurate diagnosis, including endoscopy, is essential for appropriate management, yet the real-world feasibility and clinical impact of early endoscopic evaluation remain unclear.

Methods We conducted a retrospective analysis of patients who underwent office-based, unsedated flexible sigmoidoscopy between February 2019 and April 2022 as part of the RAPID-GI program at Memorial Sloan Kettering Cancer Center. The program was designed to expedite evaluation of suspected irColitis in ICI-treated patients via rapid GI consultation including sigmoidoscopy. A diagnosis of irColitis was confirmed based on histology review by expert GI pathologists.

Results irColitis was confirmed in 70% (66/94) of patients. Median time from referral to consultation including sigmoidoscopy was 8 days. Visible inflammation was present in 80% of patients with confirmed irColitis vs. 11% without (P<0.001); all irColitis cases showed histologic inflammation. All procedures were completed without sedation using enemas alone for bowel preparation, and no complications occurred. Findings led to management changes in 89% of irColitis cases, including initiation or adjustment of immunosuppressive therapies. Among patients without irColitis, 79% avoided unnecessary immunosuppression and 57% continued or resumed ICI therapy.

Conclusions Office-based flexible sigmoidoscopy is a safe, feasible, and high-yield diagnostic tool for suspected irColitis. A rapid access program enables timely diagnosis, guides therapy, minimizes unnecessary immunosuppression, and facilitates ICI continuation. This model may improve outcomes and should be considered for broader adoption among integrated oncology and gastroenterology care teams.

Keywords Immune-related colitis, immune checkpoint inhibitors, flexible sigmoidoscopy, rapid evaluation, immune-related adverse effects

Ann Gastroenterol 2025; 38 (4): 415-419

Patterns of prescription and discontinuation of glucagon-like peptide-1 receptor agonists among patients with irritable bowel syndrome

2025-08-04T19:24:46+03:00

Background Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are associated with gastrointestinal (GI) adverse effects, but real-world evidence about their incidence in patients with functional GI disorders is limited. We examined their prescription and discontinuation patterns in irritable bowel syndrome (IBS) patients.

Methods In this retrospective analysis of GLP-1RAs prescribed to patients with IBS at our institution from 2013-2023, we assessed the association of IBS subtype- and patient-related (age, race, body mass index, insurance, diabetes, gastroesophageal reflux disease) factors on the number and reasons for agent switches throughout the treatment course.

Results Of the 256 patients with IBS prescribed >1 GLP-1RAs, 227 (88.7%) patients trialed 2-3 GLP-1RAs, while 29 (11.3%) trialed ≥4 agents. Mixed-type IBS patients showed the highest rates of switching, followed by constipation- and diarrhea-predominant type IBS (21.7%, 11.7% and 2.2%, respectively; P=0.02). Semaglutide had more discontinuations within 6 months of starting the first GLP-1RA, compared to liraglutide (63.4% vs. 43%; P=0.012). Patients aged ≥65 years were more likely to continue the first agent for >6 months compared to those <65 years (65.8% vs. 44%, P=0.014). In successive lines of therapy, treatment-related discontinuations (injection burden, non-response) remained fairly constant (17%, 14%, 14%) but symptom-related (nausea, vomiting, diarrhea, constipation) discontinuations increased steadily from first to third agent (28%, 30%, 48%, respectively). Patients with Medicare/Medicaid were more likely to switch ≥3 therapies, than those with private/self-pay coverage (23% vs. 7.3%; P=0.006).

Conclusion Our findings highlight the importance of tailoring therapy based on drug-specific and patient-related factors to optimize GLP-1RA use in IBS.

Keywords Irritable bowel syndrome, subtypes, GLP-1 receptor agonists, real-world evidence

Ann Gastroenterol 2025; 38 (4): 420-427

Trends and disparities of diverticular disease mortality in the United States before and during the COVID-19 era: estimates from the Centers for Disease Control WONDER database

2025-08-04T19:24:47+03:00

Background Diverticular disease (DD) is a common gastrointestinal condition in the United States (US) associated with significant morbidity and mortality. The COVID-19 pandemic posed new challenges that might exacerbate DD-related outcomes. This study analyzed the trends in all-cause, digestive system (DGS), and cardiovascular system (CVS) mortality associated with DD from 1999-2020, focusing on the impact of COVID-19 on age-adjusted mortality rates (AAMRs) and disparities across demographics and geography.

Methods Data from adults aged ≥25 years were extracted from the Centers for Disease Control WONDER database. AAMRs per 100,000 people were standardized using the 2000 US census. AAMRs were assessed from 1999-2020 for context, while the primary comparative analysis focused on the pre-COVID-19 (2016-2019) and post-COVID-19 (2019-2022) periods using linear regression models. AAMRs were stratified by age, sex, race/ethnicity and geographic region. Note: 2021-2022 trends were extrapolated, as finalized mortality records were not available at the time of analysis.

Results Between 1999 and 2020, 115,009 DD-related deaths occurred (AAMR 2.4/100,000), including 70,648 DGS-related deaths (AAMR 1.5) and 17,405 CVS-related deaths (AAMR 0.4). Females (AAMR 2.6), elderly individuals (AAMR 11.1), and non-Hispanic whites (AAMR 2.5) had the highest mortality rates. Post-COVID-19, AAMRs increased from 1.8 to 2.0, with significant increases among rural populations. DGS-related deaths were most prevalent, particularly in non-metropolitan areas.

Conclusions DD-related mortality has increased in the post-COVID-19 period, especially in vulnerable populations, such as the elderly, rural residents and females. These findings highlight the need for equitable healthcare interventions and the continued monitoring of pandemic-era health disparities.

Keywords Diverticular disease, COVID-19, mortality trends, disparities, CDC WONDER

Ann Gastroenterol 2025; 38 (4): 428-439

Increased capture of post-endoscopic retrograde cholangiopancreatography adverse events by delayed (day 7) follow-up calls: a prospective comparison of physician- and nurse-initiated calls

2025-08-04T19:24:47+03:00

Background Endoscopic retrograde cholangiopancreatography (ERCP) is a high-risk endoscopic procedure. We recently found that physician-initiated post-ERCP follow-up calls on day 7 post-ERCP increased adverse event capture. Subsequently, we prospectively evaluated the utility of nurse-initiated follow-up calls, comparing these with physician-initiated calls to assess the impact of transitioning this responsibility to a nurse.

Methods This prospective study was conducted on consecutive patients undergoing ERCP at our academic tertiary care medical center. Patients received phone calls on days 1 and 7 post-ERCP, from either an endoscopist or a nurse coordinator, using a standardized script to assess delayed complications (pancreatitis, non-pancreatitis abdominal pain, bleeding, infection, perforation), and unplanned health encounters.

Results A total of 448 ERCP patients (239 physician calls, 209 nursing calls) were included. Physician calls were more successful than nursing calls in reaching patients on both day 1 (96% vs. 74%, P<0.001) and day 7 (91% vs. 63%, P<0.001). Nursing calls were significantly longer than physician calls on both days. A higher adverse event capture rate by physician calls compared to nursing calls was evident on day 1 (3.5% vs. 2.4%, P=0.04) and day 7 (10.6% vs. 6.3%, P=0.004). Physician follow-up calls on day 7 resulted in substantially more patients triaged to the Emergency Department, primary care and oncology clinics (P<0.001).

Conclusions Physician calls were significantly more effective than nurse calls in reaching patients, capturing adverse events, and triaging patients to appropriate care. These data support the value of physician-initiated calls, at least following the most complex procedures.

Keywords Endoscopic retrograde cholangiopancreatography, adverse event, complication, follow up

Ann Gastroenterol 2025; 38 (4): 440-445

Patients with cystic fibrosis do not have an increased risk of adverse events after endoscopic retrograde cholangiopancreatography: a propensity-matched analysis

2025-08-04T19:24:47+03:00

Background Cystic fibrosis (CF) is a common life-limiting genetic disease often associated with hepatobiliary complications. Endoscopic retrograde cholangiopancreatography (ERCP), though valuable, carries procedural risks. We assessed the safety of ERCP in CF patients using real-world data.

Methods A retrospective cohort study using the TriNetX database (2010-2024) identified adults (≥18 years) with CF who underwent ERCP. Propensity-score matching adjusted for confounders, including age, sex, race, and hospitalization history. The primary outcome was post-ERCP pancreatitis (PEP); secondary outcomes included bleeding and infection. Subgroup analysis evaluated outcomes in patients with choledocholithiasis.

Results Among 534 matched CF patients (mean age 44.6 years; 48.3% female), rates of PEP (8.3% vs. 4.9%, adjusted odds ratio [aOR] 1.76, 95% confidence interval [CI] 0.937-3.315; P=0.075), bleeding (3.1% vs. 2.1%, aOR 1.52, 95%CI 0.674-3.409; P=0.31), and infection (3.7% vs. 2.4%, aOR 1.55, 95%CI 0.638-3.785; P=0.33) were not significantly different compared to non-CF controls. Subgroup analysis of choledocholithiasis patients similarly showed no significant differences.

Conclusions ERCP in CF patients demonstrated comparable adverse event rates to non-CF controls. These findings support the procedural safety of ERCP in this population, though further prospective studies are needed to validate these results and clarify risk by indication.

Keywords Cystic fibrosis, endoscopic retrograde cholangiopancreatography (ERCP), post-ERC pancreatitis, hepatobiliary complications, ERCP complications

Ann Gastroenterol 2025; 38 (4): 446-452

Neoadjuvant therapy versus upfront surgery approach in resectable pancreatic cancer: a systematic review and meta-analysis

2025-08-04T19:24:47+03:00

Background Pancreatic cancer is among the leading causes of cancer-related deaths worldwide. Resectable pancreatic cancer is typically treated with curative resection, often followed by adjuvant therapy. Despite this, recurrence rates remain high after resection. Additionally, micro-metastases may develop during the immediate postoperative period. To address this issue, neoadjuvant therapy has been proposed. This review aimed to assess the effectiveness of neoadjuvant treatment compared to surgery as first approach in resectable pancreatic cancer.

Methods A comprehensive literature search was conducted up to October 2, 2024, in CENTRAL, PubMed, ProQuest, SAGE and JSTOR. Randomized controlled trials (RCTs) evaluating the effects of neoadjuvant treatment in patients with resectable pancreatic cancer were included.

Results A total of 5422 articles were identified after duplicate removal. Following the screening process, 8 RCTs were included. No significant difference was observed in the overall survival (OS) among those who received neoadjuvant therapy and those who underwent upfront surgery (hazard ratio [HR] 0.92, 95% confidence interval [CI] 0.72-1.18; P=0.51). Additionally, the groups’ disease-free survival (DFS) was comparable (HR 0.98, 95%CI 0.80-1.20; P=0.83). Patients who received neoadjuvant treatment had noticeably higher R0 resection rates compared to the upfront surgery group (risk ratio 1.31, 95%CI 1.11-1.55; P=0.002).

Conclusions When compared to upfront surgery, neoadjuvant therapy significantly improved the R0 resection rates, but had no significant effect on OS or DFS. More research is required to confirm the potential benefits of neoadjuvant therapy in treating resectable pancreatic cancer.

Keywords Pancreatic cancer, neoadjuvant treatment, systematic review, meta-analysis

Ann Gastroenterol 2025; 38 (4): 453-461

Replication and extension of a meta-analysis of antidepressants for irritable bowel syndrome: a comparison of odds ratios and risk ratios using artificial intelligence-powered tools

2025-08-04T19:24:48+03:00

Authors’ reply

2025-08-04T19:24:48+03:00