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Objectives: For early gastrointestinal lesions, size is an important factor in the selection of treatment. Virtual scale endoscope (VSE) is a newly developed endoscope that can measure size more accurately than visual measurement. This study aimed to investigate whether VSE measurement is accurate for early gastrointestinal lesions of various sizes and morphologies. Methods: This study prospectively enrolled patients with early gastrointestinal lesions ≤20 mm in size visually. Lesion sizes were measured in the gastrointestinal tract visually, on endoscopic resection specimens with VSE, and finally on endoscopic resection specimens using a ruler. The primary endpoint was the normalized difference (ND) of VSE measurement. The secondary endpoints were the ND of visual measurement and the variation between NDs of VSE and visual measurements. ND was calculated as (100 × [measured size - true size] / true size) (%). True size was defined as size measured using a ruler. Results: This study included 60 lesions from April 2022 to December 2022, with 20 each in the esophagus, stomach, and colon. The lesion size was 14.0 ± 6.3 mm (mean ± standard deviation). Morphologies were protruded, slightly elevated, and flat or slightly depressed type in 8, 24, and 28 lesions, respectively. The primary endpoint was 0.3 ± 8.8%. In the secondary endpoints, the ND of visual measurement was -1.7 ± 29.3%, and the variability was significantly smaller in the ND of VSE measurement than in that of visual measurement (p < 0.001, F-test). Conclusions: VSE measurement is accurate for early gastrointestinal lesions of various sizes and morphologies.

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Objectives: To compare the efficacy and safety of sedation with midazolam and remimazolam for colorectal endoscopy. Methods: This single-center, two-arm, post-hoc analysis of the REM-IICTJP01 study investigated the efficacy and safety of remimazolam for gastrointestinal endoscopic sedation. We enrolled 40 and 208 patients who underwent colonoscopy under remimazolam and midazolam sedation, respectively, during the same period. The primary outcome was the time from the end of the colonoscopy until discharge. The secondary outcomes included the time from the end of the colonoscopy until awakening, dosage, and adverse events. Propensity score matching was employed to eliminate the effect of confounding factors. Results: Thirty-seven patients in each group were matched. After propensity matching, the time to awakening after colonoscopy was 28.0 (13.0-37.0) min in the midazolam group and 0 (0-0) min in the remimazolam group; moreover, the time till discharge was 40.0 (35.0-46.5) min in the midazolam group and 0 (0-5.0) min in the remimazolam group, both of which were significantly shorter in the remimazolam group (p < 0.01). The number of additional doses was 0 (0-0) and 2 (1-3) in the midazolam and remimazolam groups, respectively. The total dose was 2.0 (2.0-3.5) and 6.0 (5.0-7.0) mg in the midazolam and remimazolam groups, respectively. Conclusions: Remimazolam yielded significantly faster times to awakening and discharge safely compared to midazolam.

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Objective: The population-based colorectal cancer screening guidelines in Japan recommend an annual fecal immunochemical test (FIT). However, there is no consensus on the need for annual FIT screening for patients who recently performed a total colonoscopy (TCS). Therefore, we evaluated the repeated TCS results for patients with positive FIT after a recent TCS to assess the necessity of an annual FIT. Methods: We reviewed patients with positive FIT in opportunistic screening from April 2017 to March 2022. The patients were divided into two groups: those who had undergone TCS within the previous 5 years (previous TCS group) and those who had not (non-previous TCS group). We compared the detection rates of advanced neoplasia and colorectal cancer between the two groups. Results: Of 671 patients, 151 had received TCS within 5 years and 520 had not. The detection rates of advanced neoplasia in the previous TCS and non-previous TCS groups were 4.6% and 12.1%, respectively (p < 0.01), and the colorectal cancer detection rates were 0.7% and 1.5%, respectively (no significant difference). The adenoma detection rates were 33.8% in the previous TCS group and 40.0% in the non-previous TCS group (no significant difference). Conclusions: Only a few patients were diagnosed with advanced neoplasia among the patients with FIT positive after a recent TCS. For patients with adenomatous lesions on previous TCS, repeated TCS should be performed according to the surveillance program without an annual FIT. The need for an annual FIT for patients without adenomatous lesions on previous TCS should be prospectively assessed in the future.

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Colonoscopy, a widely used procedure for diagnosing and treating colonic diseases, induces transient gastrointestinal symptoms and alterations in the gut microbiota. This review comprehensively examines the evidence on alterations in the gut microbiota following colonoscopy and their possible mechanisms. Factors such as rapid colonic evacuation, increased osmolality, and mucus thinning caused by bowel preparation and exposure to oxygen during the procedure contribute to these alterations. Typically, the alterations revert to the baseline within a short time. However, their long-term implications remain unclear, necessitating further investigation. Split-dose bowel preparation and CO2 insufflation during the procedure result in fewer alterations in the gut microbiota. Probiotic administration immediately after colonoscopy shows promise in reducing alterations and gastrointestinal symptoms. However, the widespread use of probiotics remains controversial due to the transient nature of the symptoms and microbiobial alterations in the microbiota. Probiotics may offer greater benefits to individuals with preexisting gastrointestinal symptoms. Thus, probiotic administration may be a viable option for selected patients.

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There is robust evidence to indicate a strong correlation between the bowel preparation status and adenoma detection rate (ADR), which directly impacts the incidence and mortality rate of postcolonoscopy colorectal cancer. Therefore, improving bowel preparation has been of increasing interest. In Japan, commercially available bowel preparation agents include polyethylene glycol, oral sodium sulfate, sodium picosulfate-magnesium citrate, magnesium citrate, and oral sodium phosphate; each has its own strengths and limitations. The timing of administration can also influence the efficacy of bowel preparation and patient tolerability. Furthermore, meta-analyses have suggested predictive factors for inadequate bowel preparation. A detailed understanding of these factors could contribute to reducing the need for repeat colonoscopy within 1 year, as recommended for patients with inadequate bowel preparation. Recent advancements, such as oral sulfate tablets, present promising alternatives with higher patient satisfaction and ADRs than traditional methods. Achieving optimal bowel preparation requires enhanced instructions, individualized regimens, and a comprehensive understanding of patient backgrounds and the characteristics of various bowel preparation agents. This article provides a concise overview of the current status and advancements in bowel preparation for enhancing the quality and safety of colonoscopy.

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We report the case of a 70-year-old woman diagnosed with neural epidermal growth factor-like 1 antigen-positive membranous nephropathy and nephrotic syndrome. Following thorough exclusion of autoimmune diseases, medications, or infections as potential causes, colonoscopy was performed as part of malignancy evaluation, revealing an 18 mm villous adenoma in the sigmoid colon and a 7 mm tubulovillous adenoma in the cecum. Despite the absence of gastrointestinal symptoms initially and the absence of high-grade dysplasia in the pathology report, the patient experienced a remarkable improvement in symptoms and a reduction in nephrotic-range proteinuria following polypectomy, observed within a few months.

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Elastrofibromas are rare lesions characterized by collagen and elastic fiber deposition. They are generally found in soft tissues and throughout the gastrointestinal tract. The pathogenesis of this lesion is still uncertain, but it is hypothesized to be a reactive process. We present a case of an appendiceal elastofibroma, a unique anatomic location that necessitated surgical removal, with pathologic findings suggestive of an inciting event from a sclerosed vascular abnormality.

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Automatic analysis of colonoscopy images has been an active field of research motivated by the importance of early detection of precancerous polyps. However, detecting polyps during the live examination can be challenging due to various factors such as variation of skills and experience among the endoscopists, lack of attentiveness, and fatigue leading to a high polyp miss-rate. Therefore, there is a need for an automated system that can flag missed polyps during the examination and improve patient care. Deep learning has emerged as a promising solution to this challenge as it can assist endoscopists in detecting and classifying overlooked polyps and abnormalities in real time, improving the accuracy of diagnosis and enhancing treatment. In addition to the algorithm's accuracy, transparency and interpretability are crucial to explaining the whys and hows of the algorithm's prediction. Further, conclusions based on incorrect decisions may be fatal, especially in medicine. Despite these pitfalls, most algorithms are developed in private data, closed source, or proprietary software, and methods lack reproducibility. Therefore, to promote the development of efficient and transparent methods, we have organized the "Medico automatic polyp segmentation (Medico 2020)" and "MedAI: Transparency in Medical Image Segmentation (MedAI 2021)" competitions. The Medico 2020 challenge received submissions from 17 teams, while the MedAI 2021 challenge also gathered submissions from another 17 distinct teams in the following year. We present a comprehensive summary and analyze each contribution, highlight the strength of the best-performing methods, and discuss the possibility of clinical translations of such methods into the clinic. Our analysis revealed that the participants improved dice coefficient metrics from 0.8607 in 2020 to 0.8993 in 2021 despite adding diverse and challenging frames (containing irregular, smaller, sessile, or flat polyps), which are frequently missed during a routine clinical examination. For the instrument segmentation task, the best team obtained a mean Intersection over union metric of 0.9364. For the transparency task, a multi-disciplinary team, including expert gastroenterologists, accessed each submission and evaluated the team based on open-source practices, failure case analysis, ablation studies, usability and understandability of evaluations to gain a deeper understanding of the models' credibility for clinical deployment. The best team obtained a final transparency score of 21 out of 25. Through the comprehensive analysis of the challenge, we not only highlight the advancements in polyp and surgical instrument segmentation but also encourage subjective evaluation for building more transparent and understandable AI-based colonoscopy systems. Moreover, we discuss the need for multi-center and out-of-distribution testing to address the current limitations of the methods to reduce the cancer burden and improve patient care.

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Background: Most gastrointestinal polyps are asymptomatic; therefore, assessing symptoms associated with cancer and precancerous polyps is essential. Objectives: The aim of this study was to study the histopathology, number, distribution, and degree of polyps' dysplasia in terms of age, gender, and clinical presentation. Methods: This study was performed on patients who underwent endoscopy from July 2015 to August 2021 in Sulaimaniyah, Iraq. Surgical pathology records of patients were analyzed for age, sex, nature of the polyps, number, site, histopathology, degree of dysplasia, resection margins and patients' presented clinical data. Results: The mean patients' age was 51.4 ± 17.1 years, and most were males (51.9%). The most common indications for endoscopy were screening (28.62%), and the least common was weight loss (4.46%). Neoplastic polyps were common among patients with hematemesis (75%), while non-neoplastic were common among those with dyspepsia (60%). Most polyps were solitary in upper (80.8%) and lower gastrointestinal tract (GIT). Most polyps in the upper GIT were non-neoplastic (87.3%), while most lower proximal/distal GIT polyps were neoplastic. Most neoplastic polyps showed low-grade dysplasia (94.4%), and most high-grade dysplasia was a villous type (24.1%). Conclusions: Initiation of the screening program is highly recommended as a facilitating method for the early detection of multiple and high-grade gastrointestinal polyps. Thus, screening programs can reduce the rate of mortality of carcinoma in this locality.

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BACKGROUND AND AIM: Colonoscopy plays a crucial role in the early diagnosis and treatment of colorectal cancer. Adequate bowel preparation is essential for clear visualization of the colonic mucosa and lesion detection. However, inadequate bowel preparation is common in patients with constipation, and there is no standardized preparation protocol for these patients. This study aimed to explore the effectiveness and tolerability of a pre-colonoscopy combination regimen of linaclotide and polyethylene glycol (PEG). METHODS: In this prospective, single-center, randomized controlled trial, 322 participants were divided into two groups: a 3-L PEG + 870-µg linaclotide group (administered as a single dose for 3 days) and a 4-L PEG group. The primary endpoints were the Boston Bowel Preparation Scale (BBPS) score and the rate of adequate and excellent bowel preparation. Secondary endpoints were the rates of detection of colonic adenomas and polyps, cecal intubation rates, colonoscopy time, adverse reactions, patient satisfaction, and physician satisfaction. RESULTS: The study included 319 patients. The 3-L PEG + linaclotide group showed significantly higher rates of adequate and excellent bowel preparation than the 4-L PEG group (89.4% vs 73.6% and 37.5% vs 25.3%, respectively; P < 0.05). The mean BBPS score for the right colon in the 3-L PEG + linaclotide group was significantly higher than that in the 4-L PEG group. There were no significant between-group differences regarding the detection rates of colonic polyps and adenomas (44.4% vs 37.7% and 23.1% vs 20.1%, respectively; P > 0.05). There were no significant between-group differences regarding cecal intubation rates, colonoscopy operation, and withdrawal times. However, patient tolerance and sleep quality were better in the 3-L PEG + linaclotide group. CONCLUSION: The combination of 3-L PEG and 870-µg linaclotide, because of its lower volume of intake, can be considered as an alternative bowel preparation regimen for constipated patients undergoing colonoscopy, especially for the elderly.

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The remarkable recent developments in image-enhanced endoscopy (IEE) have significantly contributed to the advancement of diagnostic techniques. Linked color imaging (LCI) is an IEE technique in which color differences are expanded by processing image data to enhance short-wavelength narrow-band light. This feature of LCI causes reddish areas to appear redder and whitish areas to appear whiter. Because most colorectal lesions, such as neoplastic and inflammatory lesions, have a reddish tone, LCI is an effective tool for identifying colorectal lesions by clarifying the redder areas and distinguishing them from the surrounding normal mucosa. To date, eight randomized controlled trials have been conducted to evaluate the effectiveness of LCI in identifying colorectal adenomatous lesions. The results of a meta-analysis integrating these studies demonstrated that LCI was superior to white-light endoscopy for detecting colorectal adenomatous lesions. LCI also improves the detection of serrated lesions by enhancing their whiteness. Furthermore, accumulating evidence suggests that LCI is superior to white-light endoscopy for the diagnosis of the colonic mucosa in patients with ulcerative colitis. In this review, based on a comprehensive search of the current literature since the implementation of LCI, the utility of LCI in the detection and diagnosis of colorectal lesions is discussed. Additionally, the latest data, including attempts to combine artificial intelligence and LCI, are presented.

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Colonic lipomas (CL) are a rare condition that typically causes symptoms in only a minority of patients. When large lipomas occur, they often necessitate extensive surgery, which carries significant risks. CASE PRESENTATION: We present a case of a female patient who experienced abdominal pain and urinary urgency due to a large, 80 % obstructive lipoma in the descending colon. On abdominal Computed tomography scan, a 3.8 cm lesion with fatty density and no solid components was identified. Given its benign nature, our approach aimed to preserve the colon. This involved performing laparoscopic excision of the lipoma after marking the base of the mass with a methylene blue dye few hours prior to surgery. The patient recovered well postoperatively, with an excellent outcome, and was discharged home on the third day after surgery. DISCUSSION: Colonic lipomas are a rare finding in the gastro-intestinal tract, they are benign in nature and can cause a variety of symptoms. The diagnostic pathway can be challenging due to the broad presentation and the variable onset of symptoms. Using multiple imaging modalities (invasive and non-invasive methods) can help narrow down the diagnosis and facilitate the treatment course. CONCLUSION: Our review of literature indicated that Descending Colon lipoma is rare. With nonspecific symptoms imaging modalities such as computed tomography was used in conjunction with Colonoscopy to further delineate origin and pathology. The treatment depends on the patient's condition as well as the size and position of the tumor.

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Guidelines for managing lower gastrointestinal bleeding (LGIB) can vary significantly, posing challenges in clinical settings. This case involves a previously healthy man who presented with severe acute rectal bleeding, along with COVID-19 positivity, Janeway lesions, and splinter hemorrhages. His condition rapidly deteriorated, with evidence suggesting a diverticular bleed. Treatment with angiography and embolization successfully stabilized him, resulting in an excellent outcome. Accurate diagnosis and stabilization necessitate a coordinated approach tailored to each patient's condition. Early angiography should be considered for initial hemostasis in severe cases of LGIB, as demonstrated in this case.

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The penetration of a peritoneal dialysis catheter into the intestinal cavity is a clinically rare complication. In the present retrospective clinical case series, 11 patients with uraemia who received continuous ambulatory peritoneal dialysis and attended hospital between 2019 and 2023 are described. The median patient age was 61.91 ± 11.33 years. All patients had previously experienced peritoneal dialysis-related peritonitis and were clinically cured by infusing sensitive antibiotics into the abdominal cavity. Colonoscopy was utilised to locate the penetrating catheter and close the perforation with a titanium clip once the catheter had been removed via an external approach. Following a 2-4-week fast, the perforations healed in all 11 patients. The present authors' experience illustrates that directly removing the catheter and clamping the perforation opening under the guidance of colonoscopy is simple to operate with few complications compared with traditional open surgery.

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We present a case of metastatic rectal cancer in a 52-year-old woman, initially manifested as an acute asthma exacerbation. The patient was referred to the colorectal surgery team due to the discovery of a rectal mass after she sought treatment for shortness of breath following Clorox (cleaning product) exposure. Imaging revealed a right upper lobe nodule alongside a significant rectal mass, leading to a diagnosis of stage 4 colorectal cancer via colonoscopy and flexible sigmoidoscopy. The rectal mass was subsequently resected through robotic laparoscopic low anterior resection with coloproctostomy. This case underscores the need for clinicians to consider atypical presentations of colorectal cancer, such as asthma exacerbation, particularly in the context of the rising incidence of early-onset colorectal cancer (eoCRC). The survival rates for localized colorectal cancer are markedly higher than for metastatic cases, amplifying the need for timely and completed colorectal cancer screening. This report emphasizes the importance of increased awareness, timely diagnosis, and personalized screening strategies to improve outcomes in younger patients with colorectal cancer.

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Melanosis coli occurs with the administration of stimulant laxatives for the relief of constipation. However, the duration of macroscopic improvement of melanosis coli after discontinuation of anthracene laxatives is not well understood. We describe the case of an 81-year-old female diagnosed with melanosis coli via colonoscopy who had been taking senna laxatives for 5 years. Seven months after cessation of senna laxatives, colonoscopy showed no melanosis coli in the colon. This impressive report describes the observation of melanosis coli with colonoscopy; 7 months after the withdrawal of senna stimulant laxatives, melanosis coli resolved.

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The present case report describes the incidental discovery of cecal lymphangioma, a rare benign neoplasm originating from malformations of lymphatic vessels. Lymphangiomas are uncommon in the gastrointestinal tract, and their presence in the colon is particularly unusual. This finding adds to the limited literature on colonic lymphangiomas and emphasizes recognizing these unusual lesions. Further research is needed to understand better their clinical characteristics, potential complications, and optimal management strategies, especially in atypical locations such as the colon.

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Introduction Inflammatory bowel disease (IBD) is a chronic inflammatory condition of the gastrointestinal tract that includes ulcerative colitis (UC) and Crohn's disease (CD). The incidence and prevalence of disease are on a rising trend. Increased case detection is related to better health awareness and improved availability of diagnostic services in the community. This article aims to calculate the incidence of IBD per 1,000 colonoscopies per year and to study the clinical and demographic characteristics of patients with IBD. Methodology It was a prospective observational study done at the National Academy of Medical Sciences, Bir Hospital, Kathmandu, Nepal, from March 2023 to February 2024. All the patients who underwent colonoscopy during the study period were assessed for possible diagnosis of IBD. The Incidence rate was calculated as new IBD cases per 1,000 colonoscopies per year. Demographic and clinical profiles of the patients were collected. Results  Among 1,248 patients who underwent colonoscopy during the study period, IBD was detected in 52 patients (4.16%). UC was diagnosed in 43 patients and the incidence rate of it was calculated to be 34.4 cases per 1,000 colonoscopies per year. Similarly, CD was diagnosed in nine patients with its incidence rate being 7.2 cases per 1,000 colonoscopies per year. Disease was predominantly seen in females (F:M ratio - 1.36:1). The mean age at diagnosis of IBD was 39.67 ± 14.53 years, with patients with CD being slightly younger than those with UC. The majority of patients with UC had pancolitis. The median time to diagnosis from symptom onset was three years (range: 6 months to 7 years) for CD and 10 months for patients with UC (range: 2 months to 5 years). The most common extra-intestinal manifestations were arthralgia (11, 21.15%) and arthritis (7, 13.46%). Traditional drugs like mesalamine, prednisolone, and azathioprine were commonly prescribed. Biologics were used only in two (3.84%) patients, including infliximab and adalimumab. Janus kinase inhibitor (tofacitinib) was used in three (5.76%) patients in cases of acute severe UC. Conclusions Due to the rising trend of awareness in health and availability of colonoscopy services in our country like Nepal, the incidence of IBD is seen to be quite high. UC was seen more commonly than CD, and females were predominantly involved. The majority of patients belonged to the young and middle-aged population. The majority of patients with UC had extensive colitis, while patients with CD had ileo-colonic disease with non-stricturing, non-penetrating phenotypes. Arthralgia and arthritis were the most common extra-intestinal manifestations. Conventional drugs like mesalamine, prednisolone, and immunomodulators such as azathioprine were mostly used. The use of biologics was fairly low. This study certainly contributes to the existing literature from Nepal regarding IBD.

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Introduction: In recent years, different approaches have been used to conduct a subjective assessment of colonoscopy simulators. The purpose of this paper is to review these different approaches, specifically the ones used for computerized simulators, as the first step for the design of a standard validation procedure for this type of simulators. Methods: A systematic review was conducted by searching papers after 2010 in PubMed, Google Scholar, ScienceDirect, and IEEE Xplore databases. Papers were screened and reviewed for procedures regarding the subjective validation of computerized simulators for traditional colonoscopy with an endoscope. Results: An initial search in the databases identified 2094 papers, of which 7 remained after exhaustive review and application of exclusion criteria. All studies used questionnaires for subjective validation, with "face" being the most common validity type tested, while "content" validity and "usability" were less prominent. Conclusions: A classification of subscales for testing face validity was derived from the studies. The Colonoscopy Simulator Realism Questionnaire (CSRQ) was selected as the guide to follow for the development of future questionnaires related to subjective validation. Mislabeling of the validity tested in the studies due to ambiguous interpretations of the validity types was a common occurrence observed in the reviewed studies.

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