Annals of Gastroenterology

Electroencephalography in hepatic encephalopathy: diagnostic and prognostic applications across the disease spectrum

2026-09-07T16:45:24+03:00

Hepatic encephalopathy (HE) represents a neuropsychiatric continuum arising from cirrhosis and portosystemic shunting, where metabolic toxicity, neuroinflammation and impaired cerebral autoregulation progressively disrupt cortical network function. Minimal hepatic encephalopathy (MHE), its first and not overt stage, has been recognized as a major cause of impaired quality of life and has been associated with reduced functioning and heightened risk of progression to overt HE and mortality. Current diagnostic tools, primarily psychometric tests, capture only clinical manifestations, and lack the ability to directly examine neuronal dysfunction. Electroencephalography (EEG) provides a real-time tool to quantify brain activity, allowing the identification of subtle neural alterations long before clinical symptoms appear. Quantitative EEG (qEEG) indices, such as reduced mean dominant frequency, increased slow-wave activity and disrupted spectral ratios, consistently reflect early cognitive impairment in studies, and are correlated with liver disease severity and neurological performance. These markers not only enhance the early diagnosis of MHE, but also carry important prognostic implications: several EEG parameters have independently predicted future progression of the disease, hospitalization and mortality, and may enhance established risk models when integrated into multicomponent indices such as model for end-stage liver disease (MELD)-EEG. Collectively, evidence suggests that EEG could be used as a multidimensional and objective assessment of neural dysfunction that complements psychometric, biochemical, and imaging-based methods. Our study aimed to examine the diverse electrophysiological findings clarifying the diagnostic and prognostic importance of EEG-based markers, and to examine their possible role in early diagnosis, risk stratification and future clinical applications for patients with HE.

Keywords Cirrhosis, hepatic encephalopathy, mean dominant frequency, electroencephalography, fast Fourier transform

Ann Gastroenterol 2026; 39 (5): 497-508

A guide to healthcare maintenance for the patient with inflammatory bowel disease

2026-09-07T16:45:24+03:00

Healthcare maintenance plays a vital role in the long-term management of patients with inflammatory bowel disease (IBD), particularly those receiving immunosuppressive therapies. This review emphasizes the importance of maintaining up-to-date vaccinations, regular bone and mental health assessments, and appropriate cancer screening in this population. It also highlights the added complexity of preventive care in immunosuppressed patients, outlining specific modifications to vaccination and screening strategies required to ensure safe and effective disease management. Gastroenterologists and other clinicians involved in IBD care should remain familiar with current guidelines and consistently integrate preventive health measures into routine clinical practice.

Keywords Healthcare maintenance, inflammatory bowel disease, preventive care, screening, vaccinations

Ann Gastroenterol 2026; 39 (5): 509-522

The role of the lymphatic network in colorectal cancer: anatomy, molecular drivers and management

2026-09-07T16:45:25+03:00

Our understanding of the structures and functions of the lymphatic system in colorectal cancer (CRC) has advanced dramatically in recent years. This review aims to outline the information regarding lymphatic drainage of the colon and rectum, as well as our current knowledge of molecular determinants of lymphangiogenesis (e.g., vascular endothelial growth factor-C/-D) and the evaluation of the clinical significance of lymphatic microvessel density in cancer. The review also addresses controversies and innovations in CRC staging, including the impact of lymphovascular invasion on indications for adjuvant chemotherapy, especially in early-stage cancer. A review of current developments in the surgical treatment of CRC (transanal total mesorectal excision and lateral pelvic lymph node dissection) was also conducted, with special reference to the oncological relevance of lymphatic drainage. Knowledge of the complex structures of the lymphatic network is required to establish an individualized risk assessment, and to select the most appropriate surgical strategy in order to optimize the treatment of patients with CRC.

Keywords Colorectal cancer, lymph vessels, lymphatic network, lymphatic anatomy

Ann Gastroenterol 2026; 39 (5): 523-533

Clinical outcomes following endoscopic retrograde cholangiopancreatography-based therapy compared with surgery in chronic pancreatitis: evidence from a multicentric cohort

2026-09-07T16:45:25+03:00

Background Real-world comparative outcomes of endoscopic retrograde cholangiopancreatography-based endoscopic therapy vs. pancreatic surgery in chronic pancreatitis (CP) remain incompletely defined.

Methods We performed a retrospective comparative effectiveness study using the TriNetX US Collaborative Network. Adults with CP undergoing endoscopic therapy or pancreatic surgery were identified, and propensity score matching generated 1451 patients in each cohort. Outcomes were assessed from 1-1095 days after the index event, using risk-based analyses as the primary comparative summaries and Kaplan-Meier analyses as secondary time-to-event summaries. Outcomes included chronic opioid prescriptions, opioid use disorder (OUD), celiac plexus block/neurolysis, pain codes, acute pancreatitis, exocrine and endocrine pancreatic insufficiency, emergency visits, and all-cause mortality.

Results Mean follow up was 771.494 days for endoscopy and 827.285 days for surgery. New chronic opioid prescriptions occurred in 146/1092 (13.4%) endoscopic vs. 79/1032 (7.7%) surgical patients (odds ratio [OR] 1.862, 95% confidence interval [CI] 1.396-2.484; P<0.001; hazard ratio [HR] 1.861, 95%CI 1.415-2.448). Acute pancreatitis occurred in 167/530 (31.5%) vs. 65/565 (11.5%) patients (OR 3.539, 95%CI 2.578-4.858; P<0.001; HR 3.341, 95%CI 2.506-4.453). Exocrine pancreatic insufficiency occurred in 200/1213 (16.5%) vs. 132/1206 (10.9%) patients (OR 1.606, 95%CI 1.269-2.034; P<0.001; HR 1.585, 95%CI 1.272-1.975). Endocrine pancreatic insufficiency, mortality, emergency visits, and OUD did not differ significantly between cohorts.

Conclusions Endoscopic therapy was associated with higher chronic opioid prescribing, acute pancreatitis, celiac plexus block/neurolysis, and exocrine pancreatic insufficiency. These findings are associative and should be interpreted in the context of residual confounding and coding-based outcome ascertainment.

Keywords Chronic pancreatitis, endoscopic retrograde cholangiopancreatography, surgery, safety, outcome

Ann Gastroenterol 2026; 39 (5): 534-542

Cystic duct anatomical variations and the risk of choledocholithiasis: a systematic review and meta-analysis

2026-09-07T16:45:25+03:00

Background Cystic duct anatomy is clinically significant for surgery and stone formation, yet the literature lacks a systematic analysis linking variations to common bile duct stones. This study investigated their prevalence and risk for choledocholithiasis.

Methods We systematically searched PubMed, Embase, Web of Science and Scopus for studies on cystic duct morphology and choledocholithiasis. Pooled prevalence, risk ratios (RRs), and odds ratios were calculated using R; heterogeneity and bias were assessed via AQUA and Peter’s tests.

Results High (17.2%) and posterior (13.8%) insertions were most prevalent. Factors significantly associated with choledocholithiasis included a long cystic duct (RR 1.50, 95% confidence interval [CI] 1.18-1.90), low insertion (RR 1.46, 95%CI 1.06-1.76), spiral course (RR 1.41, 95%CI 1.06-1.86), and posterior insertion (RR 1.32, 95%CI 1.07-1.60). Lithiasis patients exhibited wider cysto-choledochal angles (47.1° vs. 40.8°). Geographic analysis revealed a high prevalence of low insertion in African populations (21.8%) and spiral ducts in East Asians.

Conclusions Cystic duct variations significantly increase susceptibility to choledocholithiasis and pose surgical challenges. As these complex anatomical courses and configurations are often missed, preoperative imaging is essential. Early identification enables safer surgical planning, reduces biliary injury risk, and can guide tailored strategies to prevent lithiasis in high-risk groups.

Keywords Choledocholithiasis, cystic duct, anatomy, risk factors

Ann Gastroenterol 2026; 39 (5): 543-551

Evaluating the role of capsule endoscopy for non-responsive, refractory and complicated celiac disease: a systematic review and meta-analysis

2026-09-07T16:45:25+03:00

Background Small-bowel capsule endoscopy (CE) is used in selected adults with nonresponsive, refractory, or complicated celiac disease (CD), but its diagnostic yield (DY), clinical impact, and safety remain uncertain.

Methods We searched Medline, EMBASE, CENTRAL, and PubMed from January 2000 to November 30, 2025, for studies of CE in adults with established CD and persistent symptoms, suspected refractory disease, or suspected complications. Two reviewers independently selected studies, extracted data, and assessed risk of bias using ROBINS-E; certainty was assessed using GRADE. Random-effects meta-analyses using generalized linear mixed models estimated pooled DY and secondary outcomes. Meta-regression and subgroup analyses were considered
exploratory.

Results Seventeen studies, including 994 adults, were eligible. The pooled DY of CE in complex CD was 82% (95% confidence interval [CI] 67-91%), with substantial heterogeneity (I2=82.5%). DY was highest in refractory CD cohorts. Pooled DY was 3% for ulcerative jejunitis and 3% for small-bowel malignancy. Capsule retention was uncommon. CE findings were associated with management changes in several studies; however, this outcome was reported in only 9 studies, and definitions varied. Egger’s test and trim-and-fill analysis suggested possible small-study effects, reducing the adjusted DY estimate to 79%. The pooled conversion to device-assisted enteroscopy
was estimated at 18% (95%CI 9-30%).

Conclusions CE may be a valuable second-line, noninvasive triage tool in selected high-risk patients with complex CD, particularly refractory CD. However, the available evidence remains of very low certainty and should be interpreted cautiously, given the substantial methodological and clinical heterogeneity across studies.

Keywords Capsule endoscopy, small bowel, diagnostic yield, refractory celiac disease, complicated celiac disease

Ann Gastroenterol 2026; 39 (5): 552-562

Lipoprotein (a) and inflammatory bowel disease: a systematic review and meta-analysis

2026-09-07T16:45:25+03:00

Background Lipid profile alterations have been reported in patients with inflammatory bowel disease (IBD). Our aim was to systematically investigate all relevant evidence on the association between lipoprotein (a) [Lp(a)] and IBD.

Methods We searched PubMed and Cochrane Library databases (up to 30 December 2024) for studies with evidence on Lp(a) in patients with IBD. A meta-analysis was performed to evaluate the mean differences (MD) in Lp(a) between patients with Crohn’s disease (CD) or ulcerative colitis (UC), and healthy controls (HC).

Results The literature search identified 11 studies (2687 participants) investigating the lipid profile of patients with IBD; however, only 6 studies were used for the meta-analysis. Overall, 1978 participants were included in the meta-analysis, of whom 1196 were IBD patients and 782 were HC. The pooled analysis from 4 studies showed that CD patients had significantly higher Lp(a) levels compared to HC (MD 18.36 mg/dL, 95% confidence interval [CI] 14.53-22.20; P<0.001). Similarly, a pooled analysis from 4 studies showed that UC patients had higher Lp(a) levels compared to HC (MD 7.32 mg/dL, 95% CI 2.85-11.79; P=0.001). A pooled analysis of 3 studies revealed a non-significant difference in Lp(a) levels between CD and UC patients. In subgroup analyses based on disease activity, CD patients with active disease exhibited significantly higher Lp(a) levels compared to those with inactive disease. No significant difference was observed in UC patients stratified by disease activity.

Conclusions Lp(a) levels are significantly higher in both CD and UC patients compared to HC. Therefore, Lp(a) evaluation is advisable when assessing IBD patients.

Keywords Inflammatory bowel disease, Crohn’s disease, ulcerative colitis, lipoprotein (a)

Ann Gastroenterol 2026; 39 (5): 563-570

Adherence of Greek gastroenterologists to established quality indicators in gastrointestinal endoscopy

2026-09-07T16:45:26+03:00

Background Quality assessment is a priority in gastroenterology. Data on adherence to endoscopy quality standards in Greece remain limited. This study examined Greek gastroenterologists’ compliance with endoscopic quality indicators.

Methods This survey collected data on the quality of upper and lower gastrointestinal endoscopy in Greece. Hellenic Society of Gastroenterology members were invited to complete an electronic survey that included validated endoscopic quality indicators.

Results In total, 164 gastroenterologists participated, of whom 107 (65%) were male. Gastroscopy duration was not recorded by 116 (71%), whereas 102 (62%) used photodocumentation. Use of Prague and Los Angeles classifications was high (156/95% and 159/97%). Complications were recorded by 103 (63.58%) after gastroscopy and 90 (55.56%) after colonoscopy. In colonoscopy, 140 (90.85%) used the Boston Bowel Preparation Scale and 158 (96.34%) achieved cecal intubation. An adenoma detection rate >25% was achieved by 117 (71.78%), and 103 (62.8%) used the Paris classification. Overall compliance with upper and lower endoscopy quality indicators was 87 (53%) and 75 (46%), respectively. Multivariate analysis showed that experience (odds ratio [OR] 2.25, 95% confidence interval [CI] 1-5.06; P=0.049), video recording (OR 2.55, 95%CI 1.23-5.28; P=0.012), and high-resolution endoscope use (OR 2.92, 95%CI 1.39-6.09; P=0.004) were associated with better compliance during upper endoscopy. For lower endoscopy significant predictors included video recording (OR 2.20, 95%CI 1.11-4.33; P=0.023), age (OR 4.33, 95%CI 1.67-11.24; P=0.003) and high-resolution endoscope use (OR 2.67, 95%CI 1.34-5.3; P=0.005).

Conclusion In this survey, discrepancies were observed in Greek endoscopists’ compliance with endoscopic quality indicators, underscoring the need for further improvement.

Keywords Quality indicators, gastroscopy, colonoscopy, endoscopy

Ann Gastroenterol 2026; 39 (5): 571-580

Safety and diagnostic accuracy of ultrasound-assisted percutaneous liver biopsy in pediatric patients: a retrospective single-center study

2026-09-07T16:45:26+03:00

Background Liver biopsy remains essential for diagnosing and managing pediatric liver diseases, despite advances in noninvasive techniques. However, data on the current indications, diagnostic yield, and safety of ultrasound-assisted percutaneous liver biopsy in children are limited.

Methods We retrospectively analyzed 60 pediatric patients who underwent ultrasound-assisted percutaneous liver biopsy at Agia Sofia Children’s Hospital between January 2018 and September 2025. Data collected included demographics, laboratory values, biopsy indications, histopathology and complications. Biopsies were performed under anesthesia using an 18-G Tru-Cut needle with real-time ultrasound guidance. Hemoglobin and hematocrit were measured pre-procedure and at 4 and 24 h post-procedure. Specimen adequacy was assessed by core length and number of complete portal tracts (CPTs).

Results The mean patient age was 8.6 years (range 1 month to 17 years), with weights from 2.9-65 kg. Indications included persistent hypertransaminasemia, cholestasis, autoimmune and metabolic liver disease, and post-transplant evaluation. Mean biopsy length was 1.12 cm (range 0.5-2 cm), with a mean of 11 CPTs (range 4-17). Histopathology revealed autoimmune hepatitis (AIH) in 38.3%, AIH with primary sclerosing cholangitis in 13.3% of patients with inflammatory bowel disease, and other diagnoses in the remainder. No major complications or postprocedural bleeding occurred. Hemoglobin and hematocrit remained stable, and all specimens were adequate for histologic assessment.

Conclusions Ultrasound-assisted percutaneous liver biopsy with an 18-G needle is safe, and yields sufficient tissue for diagnosis in pediatric patients. It continues to be indispensable for the definitive diagnosis, staging, and management of diverse liver diseases in children.

Keywords Pediatric liver disease, ultrasound-assisted percutaneous liver biopsy, diagnostic accuracy, complications, histopathology

Ann Gastroenterol 2026; 39 (5): 581-587

Functional and long-term outcomes of ileorectal versus ileal pouch–anal anastomosis for familial adenomatous polyposis: a systematic review and meta-analysis

2026-09-07T16:45:26+03:00

Background Colectomy with ileorectal anastomosis (IRA) or proctocolectomy with ileal pouch–anal anastomosis (IPAA) are the 2 standard prophylactic surgical options for patients with familial adenomatous polyposis (FAP). We aimed to compare the functional and long-term outcomes of IRA and IPAA among FAP patients.

Methods We searched large databases to identify studies evaluating the functional outcomes of prophylactic surgical modalities for FAP. The primary outcomes of interest were the functional outcomes of IRA with IPAA, including fecal incontinence, fecal urgency, use of pads for defecation, and use of antidiarrheal drugs. Secondary outcomes included the social outcomes of the 2 procedural modalities, early postoperative adverse events, and long-term adverse events.

Results Compared with IPAA, FAP patients who underwent IRA had a lower frequency of fecal incontinence (odds ratio [OR] 0.56, 95% confidence interval [CI] 0.41-0.76; P<0.001), but were more likely to have fecal urgency (OR 1.53, 95%CI 1.08-2.15; P=0.02). There was no difference in the use of pads and antidiarrheals between the 2 groups (OR 0.55, 95%CI 0.27-1.11; P=0.09; and OR 0.83, 95%CI 0.57-1.22; P=0.35, respectively). Moreover, there was no difference in social outcomes or perioperative adverse events (OR 1.19, 95%CI 0.53-2.68; P=0.68; and OR 0.73, 95%CI 0.50-1.06; P=0.10, respectively). Lastly, IRA had lower long-term complications than IPAA (OR 0.78, 95%CI 0.63-0.97; P=0.03).

Conclusion IRA has better functional outcomes regarding fecal incontinence, a better prophylactic intervention profile, and fewer long-term complications.

Keywords Familial adenomatous polyposis, adenomatous polyposis coli gene, ileorectal anastomosis, ileal pouch–anal anastomosis, meta-analysis

Ann Gastroenterol 2026; 39 (5): 588-596

Endoscopic submucosal dissection for the treatment of early Barrett’s neoplasia: long-term outcomes of a prospective multicenter study

2026-09-07T16:45:26+03:00

Background Endoscopic submucosal dissection (ESD) allows for en bloc endoscopic resection of T1 esophageal adenocarcinoma arising on Barrett’s esophagus (BE). Although the safety of the procedure is well established, the oncological adequacy of the procedure and the long-term follow up of the patients have not been prospectively studied.

Methods We conducted a prospective, multicenter study involving 9 French and Belgian centers. We included patients treated with ESD for a visible endoscopic lesion of more than 15mm documented with dysplasia, with a 3-year follow up. The primary endpoint was the histologically complete resection rate for adenocarcinoma and high-grade dysplasia (HGD).

Results A total of 141 patients were included in the study between December 2016 and January 2019. The R0 resection rate was 85% for adenocarcinoma and HGD, and 81% for invasive adenocarcinoma. The complication rate was 17%, of which 5% were early complications and 12% were late complications, mainly esophageal strictures. During a median follow-up length of 36.3 months, recurrence was observed in 15% of the patients and was endoscopically manageable in 44%. Eight patients (6%) underwent esophagectomy for a high-risk adenocarcinoma. Overall, 14 patients (12%) died during follow up, 3 of them (2.5%) from esophageal adenocarcinoma.

Conclusion Endoscopic resection by ESD is a safe and effective technique to treat T1 esophageal adenocarcinoma, allowing avoidance of esophagectomy in 94% of the patients.

Keywords Barrett’s esophagus, esophageal adenocarcinoma, early esophageal neoplasia, endoscopic submucosal dissection

Ann Gastroenterol 2026; 39 (5): 597-604

Comparative efficacy and safety of endoscopic ultrasound-guided gastrojejunostomy versus surgical gastrojejunostomy for the management of gastric outlet obstruction: a systematic review and meta-analysis

2026-09-07T16:45:27+03:00

Background Gastric outlet obstruction (GOO) is a common condition leading to impaired gastric emptying and nutritional decline. Surgical gastrojejunostomy (SGJ) has been the traditionally used bypass approach. Endoscopic ultrasound-guided gastrojejunostomy (EUSGJ) has recently emerged as a promising alternative. This systematic review and meta-analysis aimed to compare the efficacy and safety of EUSGJ vs. SGJ for the management of GOO.

Methods PubMed, Embase, MEDLINE and Cochrane were searched to identify studies that specifically compared outcomes of EUSGJ vs. SGJ in GOO patients. Outcomes assessment focused on procedural metrics and immediate postoperative recovery.

Results Nine retrospective studies incorporating 1086 patients were included. SGJ was superior in terms of technical success (odds ratio [OR] 0.16, 95% confidence interval [CI] 0.05-0.45; P<0.001). EUSGJ was superior in terms of length of hospital stay (mean difference [MD] -4.79, 95%CI -6.52 to -3.06; P<0.001), overall complications (OR 0.24, 95%CI 0.17-0.33, P<0.001), ileus (OR 0.07, 95%CI 0.02-0.17; P<0.001), operative time (MD -96.89, 95%CI -146.16 to -47.61; P<0.001) and infection (OR 0.17, 95%CI 0.08-0.37; P<0.001). No significant differences were demonstrated in terms of clinical success, reintervention, hemorrhage, and perforation.

Conclusions EUSGJ is a safe alternative to SGJ for the palliation of GOO in the arsenal of expert endoscopists. Further research is warranted to establish its place in the complex decision-making process around GOO management in the context of individualized patient care.

Keywords Endoscopic, gastrojejunostomy, gastric, obstruction, meta-analysis

Ann Gastroenterol 2026; 39 (5): 605-613

Is common variable immunodeficiency associated with diverticulitis? A matched cohort study

2026-09-07T16:45:27+03:00

Background The aim of this study was to evaluate the likelihood of acute diverticulitis and its severity in patients with common variable immunodeficiency (CVID) compared to matched controls among those who presented to the emergency room and underwent computed tomography (CT) imaging for abdominal pain.

Methods This was a multicenter, retrospective study comparing adult patients with a diagnosis of CVID, who had CT imaging for abdominal pain between the years 2015-2024, to a control cohort of adult patients without CVID. Mann-Whitney U and chi-square tests were performed to compare baseline characteristics between cases and controls. Mantel-Haenszel tests and conditional logistic regression were used to evaluate associations between CVID, diverticulitis and selected variables.

Results A total of 1392 patients were included in the analysis (696 with CVID and 696 without CVID). Of these patients, 72% were female, 96% were white, their median age was 57 years, and their median body mass index was 27.8 kg/m2. CVID was associated with lower odds of diverticulitis (odds ratio [OR] 0.41, 95% confidence interval 0.27-0.63; P<0.001). There was no difference between the rates of complicated diverticulitis. Among patients with CVID who were diagnosed with diverticulitis, 51.4% (vs. 45%, OR 1.27, 95%CI 0.57-2.81; P=0.563) required inpatient treatment, 22.9% required surgical intervention (vs. 16.5%, OR 1.50, 95%CI 1.50 (0.56-4.04); P=0.418), and 31.4% (vs. 24.1%, OR 1.45, 95%CI 0.60-3.49; P=0.411) had recurrent diverticulitis.

Conclusion Patients with CVID presenting to the emergency department have lower odds of acute diverticulitis among those who underwent CT imaging for abdominal pain.

Keywords Common variable immunodeficiency, diverticulitis, abdominal pain

Ann Gastroenterol 2026; 39 (5): 614-618

Inflammatory bowel disease and addiction: more than just smoke?

2026-09-07T16:45:27+03:00

Background Inflammatory bowel disease (IBD) is associated with comorbidities, including psychiatric disorders. However, evidence on concomitant addictions among IBD patients is lacking.

Methods This prospective multicenter cross-sectional analysis investigated the prevalence of the most common addictions (alcohol, nicotine, drugs, food and gambling) in patients with IBD in Germany, with a focus on differences between Crohn’s disease (CD) and ulcerative colitis (UC). Adult patients completed questionnaires covering addictive behavior, IBD-related and general information. Data were analyzed using standard statistical tests and correlation analyses (significance level P<0.05).

Results The study was conducted from April to October 2018, and 202 patients were included in the analysis (67.3% CD; 32.7% UC). Overall addictive behavior and nicotine addiction were more frequent in CD than in UC patients (overall: 41.2% vs. 24.3%; nicotine: 23.5% vs. 9.1%). Alcohol addiction was found in 4.9% of patients, with similar rates in CD and UC. Nicotine addiction was more frequent among females, alcohol addiction among males. Drug, food and gambling addictions were less common (5.0%, 2.0% and 0.5%) and presented only in CD patients. Significant associations were found between addictive behaviors and small intestine involvement, between nicotine addiction and educational qualification, as well as between alcohol addiction and cardiovascular risk factors, comorbidities and body mass index.

Conclusions Over a third of IBD patients exhibit addictive behaviors, with smoking being most prevalent, especially among CD patients. These findings support the recent literature, and highlight the need for interventions to address addiction risks and improve outcomes in CD and UC.

Keywords Inflammatory bowel disease, addictive behavior, Crohn’s disease, ulcerative colitis, comorbidities

Ann Gastroenterol 2026; 39 (5): 619-628