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IntroductionCapsule endoscopy is easy to perform and well tolerated but video reading is tedious, time consuming and prone to human error in the identification of imaged lesions due to the number of images produced.MethodsPatients with iron deficiency anaemia recruited from three centres (UK, Hungary and Hong Kong) had capsule endoscopy using the Navicam SB system (Ankon Technologies, China) as part of the BLITGIT study (ISRCTN85978758). Reading of videos by human experts was performed in a standard fashion, images of all lesions saved and the process timed. Videos were anonymised and randomly distributed to another member of a three member consensus panel who read the video blinded to the original findings using ProScan (Ankon Ltd), a deep learning model, in the same manner (the AI-1 read). Subsequently all lesions from both readings were reviewed by the consensus panel and graded P0, P1 or P2 (no, possible or likely bleeding lesion respectively). Lesions identified by the human expert and ProScan were considered to be the same lesion if images were considered compatible by the consensus panel and within five minutes of each other as defined by the time bar. Multiple lesions (for example, angioectasia, erosions or ulcers) were counted as the same pathology but compared in terms of their location (by tertile). An AI-2 read was performed to see if missed lesions (seen by human expert but not AI-1) were genuine AI-1 false negatives or were identified by ProScan but missed by the AI-1 reader. The gold standard was the consensus review of all images from the human expert and the AI-1 reads (lesions identified by either, irrespective of whether they were identified by one or both reads).ResultsThe mean reading time of 128 patient (62 (48.4%) female; age 58 years (IQR 45-70)) videos by human expert and AI-1 was 18.13 minutes (SD 8.34) and 2.27 minutes (SD 2.05; p<0.0001: Mann-Whitney test). Human expert, AI-1 and AI-2 identified P1 or P2 lesions in 48.4% (95%CI (40.0- 57.0)), 53.9% (45.3- 62.3) and 59.4% (50.7- 67.5) respectively, a 5.5% (2.6- 10.8) increased yield of AI-1 (p= 0.28 McNemer’s test) and 11% ((6.6- 17.5); p=0.008) of AI-2 over the human expert. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of human expert for P1 and P2 lesions were 76.5% (66.3-84.4), 100% (92.4-100), 100% (94.2-100), 71.2% (59.4-80.7) and 85.2% (78.0-90.2); of AI-1: 85.2% (75.9-91.3), 100% (92.4-100), 100% (94.7-100), 79.7% (67.7-88.0) and 90.3% (84.3-94.6) and of AI-2: 93.8% (86.3-97.3), 100% (92.4-100), 100% (95.2-100), 90.4% (79.4-95.8) and 96.8% (91.2-98.3).ConclusionsThe AI model, ProScan, was more accurate than the human expert detection of suspected small bowel bleeding lesions with an 8-fold reduction in video reading time. This confirms the findings of the ArtIC study (doi: 10.1016/S2589-7500(24)00048-7). However, readers may miss lesions presented by AI and should avoid complacency.

IntroductionGuidelines recommend upper and lower GI endoscopy to investigate the cause of iron deficiency anaemia (IDA). This practice is based on small, retrospective studies of select populations in which small bowel pathology was rarely identified. This study aimed to localise and grade all lesions with bleeding potential by performing panenteric endoscopy.MethodsPatients with IDA able to attend for capsule endoscopy in the week prior to upper and lower GI endoscopy and who had no risk factors for capsule retention were recruited from Sheffield (UK), Székesfehérvár (Hungary) and Hong Kong. Images of all upper and lower GI and small bowel lesions were assessed by a three member expert consensus panel, described using terminology from a pre-defined diagnostic register and the Saurin classification (P0: bleeding unlikely; P1: bleeding possible; P2: bleeding likely). The true prevalence of small bowel lesions in patients with IDA was assumed to be 10%, such that a sample size required to have 80% power of getting a 95% confidence interval for the prevalence no wider than 10 percentage points was 160 patients.ResultsAll gastroscopy, capsule endoscopy and colonoscopy (completion rates 99.4%, 88.2% and 95.2% respectively) data from 170 patients (median age 61 years (IQR 46- 71); 44% female) was analysed. Per-patient diagnostic yields of P1 and P2 lesions by gastroscopy, small bowel capsule endoscopy and colonoscopy were 27.6%, 49.4% and 20% (P<0.0001) and for P2 lesions alone, 6.5%, 10% and 9.4% respectively (P=0.48). P1 and P2 lesions were localised to oesophagus, stomach, small bowel, and colon in 5.5%, 18.3%, 63.0% and 13.2% respectively. P1 or P2 lesions occurred in more than one location in 27.6%.Oesophageal lesions were erosions (2.7%), ulcers (1.8%) and varices (0.9%); gastric lesions were erosions (10.5%), ulcers (2.3%), eroded polyp (2.3%), gastric antral vascular ectasia (1.4%), neoplasia (0.9%: one cancer, one a secondary lesion from lymphoma diagnosed by breast biopsy), angioectasia (0.5%), portal hypertensive gastropathy (0.5%); small bowel lesions were angioectasia (30.6%), erosions (16.4%), ulcers (10.5%), ulcerated stenosis (1.8%), fresh blood (1.8%), eroded polyp (1.4%), vascular lesion (0.9%); colonic lesions were cancer (4.1%), haemorrhoids (4.1%), angioectasia (1.8%), ulcers (1.8%) and eroded polyps (1.4%).ConclusionsThe commonest location of lesions causing IDA was the small bowel and malignant causes, the colon. A low threshold to exclude patients with possible obstructive symptoms may partly explain the absence of small bowel neoplasia. Nonetheless, important small bowel pathologies likely to cause recurrent bleeding were common and should be sought routinely in patients with IDA.

IntroductionMACE is a new, non-invasive technology which approaches the diagnostic sensitivity of OGD in gastric focal lesion detection in patients with dyspepsia. [Li et al., CGH 2016] This study compared the two in the detection of focal and diffuse lesions in patients referred for the investigation of anaemia.MethodsMACE was performed within one week before OGD using the AnX Robotica magnet system and Navicam capsule (single camera capsule, frame rate 6/sec: Wuhan, China). Following a fast, simethicone and gastric distension using 0.5–1L water, patients swallowed the capsule semi-recumbent on the left lateral side before lying supine to allow approximation of the magnet to the chest. The examination protocol included a sequence of magnet movements and patient position changes. Inspection of an anatomical location was considered complete if sufficient to exclude any significant pathology. Endoscopists performing OGD were blinded to the MACE outcome and all findings were recorded from a pre-identified diagnostic list. Data was analysed using SPSS.Results45 of 81 (55.5%; median age 63 (IQR 45.5- 72), 60% male) patients had pathology identified by MACE, OGD or both. Complete views were obtained by MACE in the oesophagus (72.4%), proximal stomach (93.8%), distal stomach (93.8%) and duodenum(79.6%, p<0.001) and mean examination time was 22 minutes.Findings were concordant in 17 (37.8%: gastric erosions (n=6), ulcers (n=5), oesophagitis (n=2), eroded polyps (n=2) and gastric antral vascular ectasia (n=2)). MACE alone identified pathology in 24 (53.3%: gastric erosions (n=17), angioectasia (n=4), ulcers (n=2, oesophageal and duodenal), eroded polyp (n=1) and both angioectasia and erosions (n=1). OGD identified a distal body ulcer (n=1), small (n=1) and large (n=1) oesophageal varices and oesophageal ulcers (n=1) missed by MACE and in one patient MACE identified only an oesophageal ulcer and OGD only a duodenal ulcer, each missing the pathology detected by the other. Diagnostic yield was higher for MACE than OGD (P<0.001).ConclusionsThe improved diagnostic yield of MACE compared to OGD is accounted for mainly by minor mucosal abnormalities which could, nonetheless, contribute to occult bleeding and anaemia. Although speculative this could be because of better tolerance of MACE and a longer examination time. An increased frame capture rate, with or without a second camera, is needed to improve oesophageal visualisation.

IntroductionCurrent guidelines suggest upper and lower GI endoscopy to investigate iron deficiency anaemia (IDA) because of a perceived low risk of small bowel pathology. This is the first study to investigate the entire gastrointestinal tract to localise lesions suspected of causing blood loss in patients with IDA.MethodsPatients referred to three centres (Sheffield, Hong Kong and Szekesfehervar, Hungary) for the investigation of IDA underwent small bowel (SB) capsule endoscopy (Navicam, AnX Robotica, Plano, US) a week prior to upper and lower gastrointestinal endoscopy. All lesions were described using terms selected from a predetermined diagnostic list and according to the perceived likelihood of bleeding (P0: unlikely; P1: suspected; P2: likely. Saurin et al., Endoscopy 2003).ResultsAssuming a true prevalence of small bowel lesions of 10% in patients with IDA, a sample size required to have 80% power of getting a 95% confidence interval for the prevalence no wider than 10 percentage points is 160 patients. 167 patients (median age 60 years (IQR 46–72); 53.0% male) had a median haemoglobin of 102.5 g/L (IQR 92.5–117.0), ferritin 11(IQR 7- 18) and iron 6 (IQR 4- 10). Completion rates for gastroscopy, colonoscopy and capsule endoscopy were 99.4%, 95.0% and 90.0% respectively. Diagnostic yield of P1/P2 lesions by SB capsule (46.7%) was higher than gastroscopy (28.0%) and colonoscopy (31.0%); p<0.001. Four patients were diagnosed with coeliac disease based on capsule endoscopy and duodenal biopsy. A further three patients had fresh blood seen on capsule the source of which was unclear.Abstract O10 Table 1Number of patients with P1/P2 pathology identified at gastroscopy, SB capsule and colonoscopy Gastroscopy pathology Small bowel pathology Colonoscopy pathology Oesophageal ulcer:Oesophageal Varices:Gastric tumour:Gastric ulcers:Gastric angioectasia:Gastric erosions:Gastric polyp with eroded surface:GAVE:PHG:Large friable duodenal adenoma:Duodenal ulcerDuodenal erosions:Duodenal angioectasia: 72251243311252 Angioectasia:Small bowel ulcers:Ulcerated stenosis:Polyp with eroded surface:Small bowel erosions: 512132 30 Colorectal cancer:Haemorrhoids:NSAID induced ulcer:Terminal ileal ulceration:Terminal ileal erosions:Angioectasia:IBD:Radiation proctitis: 822143222ConclusionPathology suspected of, or likely to be, causing blood loss in patients with IDA appears to be commoner in the small bowel than the proximal GI tract or colon. Small bowel examination should be performed routinely to maximise diagnostic yield.

IntroductionCurrent guidelines suggest upper and lower GI endoscopy to investigate iron deficiency anaemia (IDA) because of a perceived low risk of small bowel pathology. We aimed to identify the Bleeding Location In The Gastrointestinal Tract (BLITGIT) in patients with IDA.MethodsPatients referred to three centres (Sheffield, Hong Kong and Szekesfehervar, Hungary) for the investigation of IDA underwent small bowel (SB) capsule endoscopy (Navicam, AnX Robotica, Plano, US) in the week prior to upper and lower gastrointestinal endoscopy. All lesions were described using terms selected from a predetermined diagnostic list and according to the perceived likelihood of bleeding (P0: unlikely; P1: suspected; P2: likely. Saurin et al., Endoscopy 2003).Results92 patients (median age 61 years (IQR 45–72); 54.3% male) had a median haemoglobin of 107.5 g/L (IQR 93.2–121.7), ferritin 8(IQR 8- 18) and iron 3.8(IQR 3.8- 6.4). Completion rates for gastroscopy, colonoscopy and capsule endoscopy were 98.9%, 95.6% and 84.7% respectively. Diagnostic yield of P1/P2 lesions by SB capsule (48.9%) was higher than gastroscopy (27.1%) and colonoscopy (29.3%; p=0.003). On multivariant analysis there was no correlation between age, haemoglobin level, symptoms or medication on pathology. A few patients had more than one P1/P2 lesions. In 25 (27.1%) patients P1/P2 pathology was identified on gastroscopy. In 45 (48.9%) patients P1/P2 pathology was identified in the SB. On colonoscopy 27 (29.3%) patients had P1/P2 pathology. Three patients had colorectal cancer and two patients had a new diagnosis of ulcerative colitis.Abstract P167 Table 1Number of patients with P1/P2 pathology identified at gastroscopy, SB capsule and colonoscopy. Dy= diagnostic yield Gastroscopy pathology (P1/P2) Small bowel pathology (P1/P2) Colon pathology (P1/P2) Oesophagitis- 2Oesophageal ulcer- 1Oesophageal varices- 2Gastric erosions- 9Gastric ulcer- 5Gastric polyp with blood- 1Gastric antral vascular ectasia -2Portal hypertensive gastropathy – 1Duodenal ulcer- 3 Angioectasia- 23Erosion - 18Ulcers- 16Polyp with eroded surface- 1Single diverticula- 1Fresh blood- 3Portal hypertensive enteropathy- 1 Haemorrhoids- 15Colorectal cancer- 3Ulcerative colitis- 2Diverticulitis-2NSAID induced Ulcers- 1Angioectasia- 2Radiation proctitis- 2 ConclusionsThe diagnostic yield in the small bowel is higher as compared to the upper and lower GI tract and examination should be considered routinely.

Introduction Recently prophylactic placement of a trans-sphincteric pancreatic stent has successfully been applied to prevent post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. Rescue ERCP and emergency application of small-caliber pancreatic stents during the early course of post-ERCP pancreatitis as a possible endoscopic therapy has not been reported yet. Methods All patients who underwent ERCP were hospitalized for at least 24 h, with routine laboratory testing of amylase levels. Out of 1,225 ERCPs, evolution of severe post-ERCP pancreatitis was anticipated in six consecutive patients, based on severe pancreatic pain attack, more than tenfold elevation of serum amylase levels at 8 and 24 h, and moderate rise of white blood cell (WBC) and C-reactive protein (CRP) levels. Rescue ERCP and emergency application of small-caliber (4-5F, 4-cm, Geenen stent) pancreatic stents were successfully performed in all patients within 8–20 h after the initial ERCP. Results Moderate to severe papillary oedema was observed in all patients during the rescue ERCP. Pancreatic pain was promptly reduced after the rescue pancreatic drainage procedure and completely diminished within 24 h after pancreatic stenting. Serum amylase levels were exponentially reduced and normalized within 72 h in all patients; no pancreatic necrosis or any other late complications were observed. Pancreatic stents could be safely removed a few days later. Conclusion Rescue pancreatic stenting with small-caliber prophylactic pancreatic stents seems to be a safe and effective procedure that might be feasible to stop the evolution of severe post-ERCP pancreatitis, but prospective controlled studies are clearly demanded to support this innovative approach.

Similar Genetic Features and Different Islet Cell Autoantibody Pattern of Latent Autoimmune Diabetes in Adults (LADA) Compared With Adult-Onset Type 1 Diabetes With Rapid Progression Nóra Hosszúfalusi , MD, PHD 1 , Ágnes Vatay , MD 1 , Katalin Rajczy , PHD 2 , Zoltán Prohászka , MD, PHD 1 , Éva Pozsonyi , MD 2 , Laura Horváth , MD, PHD 1 , Andrea Grosz , MD 3 , László Gerõ , MD, DSC 4 , László Madácsy , MD, DSC 5 , László Romics , MD, DSC 1 , István Karádi , MD, DSC 1 , George Füst , MD, DSC 1 and Pál Pánczél , MD, PHD 1 1 Third Department of Internal Medicine, Semmelweis University, Budapest 2 National Institute of Hematology and Immunology, Budapest 3 Polyclinic of Hospitaler Brothers of Saint John’s of God, Budapest 4 First Department of Internal Medicine, Semmelweis University, Budapest 5 First Department of Pediatrics, Semmelweis University, Budapest, Hungary Abstract OBJECTIVE —To compare the clinical parameters, C-peptide levels, pattern of islet cell-specific autoantibodies, and prevalence of predisposing genotypes in subjects with latent autoimmune diabetes in adults (LADA) and those with adult-onset type 1 diabetes with rapid progression. RESEARCH DESIGN AND METHODS —We evaluated the clinical parameters, C-peptide levels, and islet cell-specific autoantibodies in 54 LADA, 57 adult-onset type 1 diabetic, and 190 type 2 diabetic patients. Islet cell autoantibodies were also compared between subgroups of newly diagnosed patients with LADA and those with newly diagnosed adult-onset and childhood-onset type 1 diabetes. The genetic study was performed in subjects with LADA and those with adult-onset type 1 diabetes in comparison with a control population. RESULTS —There were no differences in the clinical parameters between LADA and adult-onset type 1 diabetes. Patients with LADA had lower BMI ( P < 0.0001), waist-to-hip ratio (0.0029), total cholesterol ( P = 0.001), and triglycerides ( P = 0.001); higher HDL cholesterol levels ( P < 0.0001); and lower prevalence of hypertension ( P = 0.0028) compared with patients with type 2 diabetes. C-peptide levels were similar at onset ( P = 0.403) but decreased less rapidly in LADA than in adult-onset type 1 diabetes ( P = 0.0253). Single-autoantibody positivity was more often seen in LADA than in type 1 diabetes ( P = 0.0001). The prevalence of predisposing HLA-DQB1*0302, -DR4, -DR3, and -DR3/DR4 genotypes and the DR4-DQB1*0302 haplotype were increased in both LADA and adult-onset type 1 diabetic subjects compared with the control population. There were no differences in the frequencies of these risk alleles and haplotypes between the two patient groups. CONCLUSIONS —Subjects with LADA had clinical characteristics similar to those with adult-onset type 1 diabetes with rapid progression. C-peptide levels did not differ at onset but decreased less rapidly in LADA. Patients with LADA rather had single islet cell-specific autoantibody positivity. The prevalence of HLA-DQB1*0302, -DR4, -DR3, and -DR3/DR4 risk alleles and the DR4-DQB1*0302 high-risk haplotype did not differ in the two forms of autoimmune diabetes. GADA, GAD 65 autoantibody ICA, islet-cell cytoplasma autoantibody IA-2A, tyrosine phosphatase-like protein IA-2 autoantibody JDF, Juvenile Diabetes Foundation LADA, latent autoimmune diabetes in adults SSP, sequence-specific polymorphism UKPDS, U.K. Prospective Diabetes Study Footnotes Address correspondence and reprint requests to Nóra Hosszúfalusi, Budapest Kútvölgyi út 4, H-1125, Hungary. E-mail: hono{at}kut.sote.hu . Received for publication 1 February 2002 and accepted in revised form 14 October 2002. A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances. See accompanying editorial, p. 536. DIABETES CARE

Introduction The aim of this study was to determine the level of awareness of hypoglycemia, the level of fear for hypoglycemia, and the response to hypoglycemic events among insulin-treated diabetes patients from Central and Eastern Europe (CEE). The impact of hypoglycemia on the use of healthcare resources and patient productivity was also assessed. Methods This was a multicenter, non-interventional, two-part, patient self-reported questionnaire study that comprised both a retrospective cross-sectional evaluation and a prospective observational evaluation. Study participants were insulin-treated adult patients with type 1 diabetes mellitus (T1DM) or type 2 diabetes mellitus (T2DM) from CEE. Results Most patients (85.4% T1DM and 83.6% T2DM) reported normal hypoglycemia awareness. The median hypoglycemia fear score was 5 out of 10 for T1DM and 4 out of 10 for T2DM patients. Patients increased glucose monitoring, consulted a doctor/nurse, and/or reduced the insulin dose in response to hypoglycemia. As a consequence of hypoglycemia, patients took leave from work/studies or arrived late and/or left early. Hospitalization was required for 31 (1.2%) patients with T1DM and 66 (2.1%) patients with T2DM. Conclusion Hypoglycemia impacts patients’ personal and social functioning, reduces productivity, and results in additional costs, both direct (related to increased use of healthcare resources) and indirect (related to absenteeism. Funding Novo Nordisk.

Gastrointestinal complaints are common in diabetes mellitus. However, its association to peripheral sensorimotor and autonomic neuropathies is not well investigated. The aim was to assess skin, muscle, bone and visceral sensitivity in diabetes patients with sensorimotor neuropathy, and correlate these with gastrointestinal symptoms and degree of cardiac autonomic neuropathy. Twenty patients with sensorimotor neuropathy (65% type 2 diabetes, aged 58.3±12.0years, diabetes duration 15.8±10.0years) and 16 healthy controls were recruited. Cutaneous sensitivity to von Frey filaments, mechanical allodynia, muscle/bone/rectosigmoid sensitivities, and heart rate variability were examined. Gastrointestinal symptom scores (PAGI-SYM) and health-related quality of life (SF-36) were also recorded. Patients displayed hypesthesia to von Frey filaments (p=0.028), but no difference to muscle and bone pain sensitivities. Also, patients were hyposensitive to multimodal rectal stimulations (all p<0.05), although they suffered more gastrointestinal complaints. Heart rate variability was reduced in the patient cohort. Rectal mechanical and cutaneous sensitivities correlated (p<0.001), and both were associated with heart rate variability as well as PAGI-SYM and SF-36 scores (p<0.01). In diabetic sensorimotor neuropathy there is substantial evidence of concomitant cutaneous, cardiac and visceral autonomic neuropathies. The neuropathy may reduce quality of life and explain the higher prevalence of gastrointestinal complaints.

Background The aims of the present study were: (1) to assess the feasibility and safety of emergency endoscopic retrograde cholangiopancreatography (ERCP) and pancreatic duct (PD) stenting with small-caliber stents as a bridging procedure in acute biliary pancreatitis (ABP) patients in whom biliary endoscopic sphincterotomy (EST) proved difficult, failed or was contraindicated, and (2) to compare the clinical outcome of those patients having emergency ERCP with and without pancreatic stent. Method Eighty-seven consecutive patients with ABP were referred for emergency ERCP. In 60 of these ABP patients, ERCP, EST, and stone extraction (if necessary) were performed without PD stenting. In the remaining 27 patients, small-caliber (3–5 F, 4 cm) pancreatic stent insertion was initially applied. All patients were hospitalized for medical therapy and were followed up. Results The mean ages, the initial symptom-to-ERCP times, the Glasgow severity scores, and the peak amylase and CRP levels at initial presentation were not significantly different in the ERCP + EST with PD stent group versus the ERCP + EST without PD stent group. More importantly, the complication rate was significantly lower in the ERCP + EST with PD stent group versus the ERCP + EST without PD stent group (7.4% vs. 25%); while the mortality rates (0% vs. 6.7%) were comparable, reasonably low, and demonstrated no statistically significant differences. Conclusions Temporary PD stenting with small-caliber stents is a safe and effective procedure that may afford sufficient PD decompression to reverse the process of ABP and serve as a bridging procedure in severe ABP in patients with failed, complicated, or contraindicated biliary EST.