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Background and Study Aims: Endoscopic retrograde cholangiopancreatography (ERCP) in surgically altered anatomy patients is challenging. We analyzed ERCP procedures after gastric surgery with maintained Vater's papilla: total/partial gastrectomy Roux-en-Y, Billroth II gastrectomy, sleeve gastrectomy and gastrojejunostomy., Methods: Monocentric retrospective analysis of prospective ERCP cohort in surgically altered gastric anatomy (SAGA) patients with maintained Vater's papilla between 2006 and 2024., Results: 186 ERCP procedures in 110 patients with SAGA proportions: 37% total gastrectomy Roux-en-Y, 32% Billroth II partial gastrectomy, 15% partial gastrectomy Roux-en-Y, 11% gastrojejunostomy, 4% sleeve gastrectomy and 1% less common reconstructions. ERCP indications were mainly biliary (87%). Total technical success was 82% with lower technical success in Roux-en-Y gastric surgery (73%) vs gastric surgery without Rouxen- Y (92%). 13 adverse events (GRADE II - IV) were encountered (7%) with 1 mortality due to perprocedural cardiac arrest. Sleeve gastrectomy allowed the use of conventional duodenoscopes with 100% technical success. In Billroth II patients both duodenoscopes, gastroscopes and colonoscopes as well as balloon-assisted enteroscopes were used with high technical success (94-100%), as well as in gastrojejunostomy patients (57-100%). For Roux-en-Y reconstructions, only single-balloon enteroscopes were used with acceptable success (75% in partial and 74% in total gastrectomy Roux-en-Y)., Conclusions: ERCP in SAGA patients is challenging requiring different types of endoscopes, especially after Roux-en-Y total or partial gastrectomy with lower technical success as compared tods Billroth II gastrectomy, sleeve gastrectomy and gastrojejunostomy. Adverse event rates are comparable to ERCP procedures in patients with normal anatomy., Competing Interests: The authors declare that they have no conflict of interest, (© Acta Gastro-Enterologica Belgica.)

Introduction: Medical malpractice litigations represent a reality for clinical physicians. However, no data are available about the impact on gastroenterologists in Belgium., Aim: We estimated the number of malpractice litigations against gastroenterologists in Belgium based on the annual reports of the Fund for Medical Accidents (FMA), residing under the Belgian national social security service (RIZIV-INAMI)., Methods: FMA annual reports are available online in the public domain from 2012 onwards. We reviewed all available annual reports, focussing on results within the fields of Gastroenterology and Cardiology., Results: From 2010 to 2023 a total of 6884 applications for malpractice litigations were filed resulting in a final decision for 3185 care providers between 2014 and 2023. In this 10 years period claims were filed against 92 gastroenterologists, placing them in the top 10 of care providers at risk for malpractice litigations in Belgium. There are currently 777 practicing gastroenterologists in Belgium, indicating that over 10 years time the cumulative risk of malpractice litigation through the FMA alone is as high as 12%. The subject of the claims is not mentioned in the FMA reports, and therefore remains unknown. Compared to Cardiology, another interventional speciality within the field of Internal Medicine, gastroenterologists are more prone to malpractice litigations. Only 73 (6%; p<0.001 Chi-square) on a total of 1237 practicing cardiologists faced malpractice litigations through the FMA., Conclusion: Based on the FMA annual reports, Belgian gastroenterologists are considerably at risk of malpractice litigations reaching 12% over a 10 years time period, as compared to only 6% cumulative risk of practicing cardiologists. Endoscopy-related complications are supposedly the most common reason of malpractice litigation and Belgian gastroenterologists should be aware of this risk., (© Acta Gastro-Enterologica Belgica.)

Background and Study Aims: Motorized spiral enteroscopy is proven to be effective in antegrade and retrograde enteroscopy. Nevertheless, little is known about its use in less common indications. The aim of this study was to identify new indications for the motorized spiral enteroscope., Methods: Monocentric retrospective analysis of 115 patients who underwent enteroscopy using PSF-1 motorized spiral enteroscope between January 2020 and December 2022., Results: A total of 115 patients underwent PSF-1 enteroscopy. 44 (38%) were antegrade procedures and 24 (21%) were retrograde procedures in patients with normal gastrointestinal anatomy with conventional enteroscopy indications. The remaining 47 (41%) patients underwent PSF-1 procedures for secondary less conventional indications: n=25 (22%) enteroscopy-assisted ERCP, n=8 (7%) endoscopy of the excluded stomach after Roux-en-Y gastric bypass, n=7 (6%) retrograde enteroscopy after previous incomplete conventional colonoscopy and n=7 (6%) antegrade panenteroscopy of the entire small bowel. In this group of secondary indications, technical success rate was significantly lower (72.5%) as compared to technical success rates in the conventional groups (98-100%, p<0.001 Chi-square). Minor adverse events occurred in 17/115 patients (15%), all treated conservatively (AGREE I and II)., Conclusion: This study demonstrates the capabilities of PSF-1 motorized spiral enteroscope for secondary indications. PSF-1 is useful to complete colonoscopy in case of long redundant colon, to reach the excluded stomach after Roux-en-Y gastric bypass, to perform unidirectional pan-enteroscopy and to perform ERCP in patients with surgically altered anatomy. However, technical success rates are lower as compared to conventional antegrade and retrograde enteroscopy procedures, with only minor adverse events., (© Acta Gastro-Enterologica Belgica.)

Background and Study Aims: Gastrointestinal endoscopic procedures have evolved significantly in the last sixty years revolutionising the approach to the diagnostic and therapeutic spheres of medicine. Despite the advantages of using natural orifices to the bowel, adverse events (AE) may occur following endoscopy. Systematic AE registration is an objective in every realm of quality medicine. Despite the obvious advantage as a quality indicator, tracking endoscopy-related AE is not evident. The current study aimed at tracking all AE of all endoscopic procedures during a 3-month period. The three methods used were voluntary reporting by the endoscopist and by the patient in parallel with retrospective data analysis of patients' electronic medical records to allow capture of all AE and comparison of the three methods., Patients and Methods: During a 3-month period endoscopists and patients were requested to report any possible AE. At the end of the period, a systematic review of all patient files was performed to track all AE related to the endoscopic procedure or the endoscopyrelated anaesthesia. In total 2668 endoscopic procedures were reviewed., Results: The total AE rate was 1.95%. Only half (51.9%) of all AE were voluntarily reported by endoscopists, the other half were extracted from the electronic medical record. There were no patient-reported AE. Although the majority (66.7%) of unreported AE were mild, these findings illustrate that voluntary AE reporting is unreliable. However, the retrospective tracking process proved to be difficult and time-consuming., Conclusions: The current study highlighted that systematic registration of all endoscopy-related AE is feasible, but challenging because of multiple hurdles. More practical methods are warranted to obtain reliable and long-term data as part of endoscopy quality measures., Competing Interests: The authors declare that they have no conflict of interest, (© Acta Gastro-Enterologica Belgica.)

We present the case of a 59-years-old woman with a history of abdominal pain and iron-deficiency anemia. Upper and lower gastrointestinal endoscopy turned out negative and further investigation with wireless videocapsule showed an inflammatory stricture in the middle of the small bowel with retention of the videocapsule. Treatment with budesonide was initiated and allowed the spontaneous evacuation of the videocapsule. Retrograde motorized spiral enteroscopy was performed and confirmed an ulcerative stricture 60 cm proximal to the ileocaecal valve. Clinical, iconographic, endoscopic and histological results were compatible with a rare entity described as cryptogenic multifocal ulcerative stenosing enteritis (CMUSE). After the diagnosis budesonide was replaced by azathioprine 100 mg/d as an immunosuppressor. However, azathioprine induced mild pancreatitis and a second course of budesonide was started again. Clinical evolution was favorable., (© Acta Gastro-Enterologica Belgica.)

Background and Study Aims: Data on procedural outcome and quality of endoscopic retrograde cholangiopancreatography (ERCP) in Belgian practice are scarce. The aim of this study is to assess current status of ERCP-performance in Belgium., Methods: National multi-institutional survey (online questionnaire) among members of the Belgian Society of Gastrointestinal Endoscopy (BSGIE), conducted in the period June-August 2018. The RIZIV/INAMI provided real-life data on the total number of ERCPs performed in Belgium., Results: Forty-five responders completed the survey (for 43 centers performing ERCP), providing information for 8368 ERCPs performed in 45% (43/95) of institutions performing ERCP in Belgium. Fifty-eight percent of centers performed > 100 ERCPs/year and 7% of centers (n=3) performed < 50 ERCPs/year. According to the RIZIV/INAMI data, low case-volume centers are underrepresented in this survey. The most common ERCPindication was stone extraction (52%). 74% of endoscopists had more than 10 years of experience in performing ERCP. The majority of centers had their own written protocol (84%) for microbiological duodenoscope surveillance. Monitoring of cannulation rate and post-ERCP pancreatitis (PEP) was only performed in a minority of centers (30%). The majority of centers (76%) provided verbal informed consent relating to the ERCP-procedure ; a minority also requested a written informed consent (23%). 65% of centers systematically use NSAIDs for PEP prophylaxis., Conclusion: This is the first survey of ERCP performance in Belgium. There were wide variations in practice. Adherence to key performance measures and measurement and evaluation of ERCP performance in daily practice at center and endoscopist level are not uniformly widespread., Competing Interests: The authors declare that they have no conflict of interest, (© Acta Gastro-Enterologica Belgica.)

We report a case of a 67-years-old woman presenting a severe acute lymphocytic gastritis induced by pembrolizumab, an immune check point inhibitor (ICI). This gastritis was her third auto-immune adverse event after 5 years of treatment with pembrolizumab, it was metabolically active at the PET Scan and confirmed by analysis of the gastric biopsies. Pembrolizumab treatment cessation and high doses of corticosteroids completely normalized the stomach clinically, endoscopically and histologically. This patient was in complete remission of her metastatic melanoma. Therefore, pembrolizumab therapy was not restarted and the patient is still in remission 6 months later. This strategy is supported by recent publications describing a relapse rate inferior to 10% in patients in complete remission after 2 years of immunotherapy. Particularities of this case are: rareness of this adverse event, late onset after introduction of pembrolizumab, evocative PET scan image, specific endoscopic aspect and histology. In addition, the favorable oncologic evolution of the patient after treatment cessation confirms the prolonged remission after immunotherapy., Competing Interests: The authors declare that they have no conflict of interest, (© Acta Gastro-Enterologica Belgica.)

Background and Aims: With the first wave of the COVID-19 pandemic declining, activities in the gastrointestinal clinic are being recommenced after a period of stringent measures. Since a second COVID-19 wave is not entirely ruled out health care professionals might remain faced with the need to perform endoscopic procedures in patients with a confirmed positive or unknown COVID-19 status. With this report we aim to provide a practical relevant overview of preparation and protective measures for gastroenterologists based on the currently available guidelines and our local experience and results of a national Belgian survey, to guarantee a fast recall of an adequate infection prevention if COVID-19 reoccurs., Methods: From the 23rd of March 2020 and the 13th of May 2020 we performed a Pubmed, Embase and Medline search, resulting in 37 papers on COVID-19 and endoscopy. Additionally, we combined these data with data acquired from the national BSGIE survey amongst Belgian gastroenterologists., Results: Based on 72 completed surveys in both university and non-university hospitals, the results show (1) a dramatic (<20%) or substantial (<50%) decrease of normal daily endoscopy in 74% and 22% of the units respectively, (2) a difference in screening and protective measures between university and non-university hospitals. These findings were subsequently compared with the current guidelines., Conclusion: Based on new data from the BSGIE survey and current guidelines we tried to realistically represent the current COVID-19 trends in protective measures, screening and indications for endoscopy and to provide a practical overview as preparation for a possible second wave., Competing Interests: The authors declare that they have no conflict of interest, (© Acta Gastro-Enterologica Belgica.)

Background: The natural history of ulcerative colitis (UC) is unpredictable. Factors associated with the need for different types of step-up therapy in UC patients failing on 5-aminosalicylic acid (5-ASA) or corticosteroids are understudied., Aims: Describe step-up therapy in patients with UC the first year after failing on 5-ASA or corticosteroids., Methods: A Belgian, multi-center, prospective, non-interventional observational study comprising adult UC patients failing on 5-ASA or corticosteroids and naïve to immunomodulators/ biologicals. During a 12 months follow-up, patient characteristics, demography, medical therapy, biomarkers, therapy adherence and quality of life (QoL) were assessed., Results: After 1 year, 35% of the patients were on biological therapy. Use of anti-TNF differed depending on baseline treatment: corticosteroid-refractory patients (55.8%), 5-ASA refractory (20.0%), and corticosteroid-dependent (16.0%) patients (p<0.001). The decision to start a line of therapy was based on the Mayo combined severity but not on biomarkers like faecal calprotectin, haemoglobin, CRP, albumin, platelets, and number of extraintestinal manifestations. At year 1, 84.2% of the patients had only mild UC or remission and a significant improvement of fatigue (p=0.004) and IBDQ scores (p<0.001) were observed implying an improved QoL., Conclusion: Treatment step-up, based on clinical scores in immunomodulatory and anti-TNF naïve patients with UC, provides good clinical outcomes and QoL., (© Acta Gastro-Enterologica Belgica.)

The history of Acta Gastro-Enterologica Belgica is long, rich… and cloudy. There is no centralised archive available. However, all currently active gastroenterologists in Belgium have been trained with the journal, have published abstracts or manuscripts in it, or at least know of its existence. Whereas it started as a national society's journal in 1933, it has grown to a competitive international journal with Impact Factor. We felt the need to reconstruct the journal's long history, since this was never done before. This review tried to highlight some of the important milestones, without claiming to be complete. Looking back helps to better foresee and anticipate the future., (© Acta Gastro-Enterologica Belgica.)

Background and Study Aims: Anti-TNF monoclonal antibodies are a cornerstone in the treatment of Crohn's disease. Prospective data on switching from the subcutaneous and human adalimumab (ADM) to the intravenous and chimeric infliximab (IFX) are scarce., Patients and Methods: In this prospective, observational, multicentre cohort study we included 21 patients with loss of response to ADM despite at least 4 consecutive weekly injections. Clinical response (CDAI drop≥70 points) and remission (CDAI≤150) were assessed after switching from ADM to IFX after 10 weeks, 6 and 12 months. Predictive factors of response/remission, the need for therapy intensification, discontinuation and safety were investigated., Results: Short-term response and remission (10 weeks) were seen in 57% and 48% respectively. Mid- and long-term clinical response and remission were achieved in 40% and 25% after 6 months and in 45% and 20% after 12 months respectively. At 12 months, 81% still were on IFX. IFX therapy intensification was needed in half of the patients at 6 months and three quarter of patients at 12 months. Undetectable ADM trough levels (despite weekly injections) were a predictive factor for short-term response and remission to IFX. About half of the patients with response at week 10 maintained response at 6 and 12 months., Conclusions: Switching from ADM to IFX can be efficacious in patients with loss of response, in particular in case of undetectable ADM trough levels. The majority of patients however will need IFX therapy intensification during their first year of treatment., (© Acta Gastro-Enterologica Belgica.)

Endoscopic retrograde cholangiopancreatography (ERCP) in Billroth II patients is challenging and different endoscopes can be used. We retrospectively analysed 67 ERCP procedures in 38 Billroth II patients focussing on endoscope type and respective technical success and adverse event rate. 33 (49.2 %) ERCPs were performed using a duodenoscope, 87.9 % were successful and 3 were completed with the single-balloon enteroscope. 28 (41.8 %) ERCPs were performed with the single-balloon enteroscope, 82.1 % were successful and 2 were completed with a paediatric colonoscope. For 6 (9.0 %) ERCPs a paediatric colonoscope was used but only 3 (50.0 %) were successful. Overall technical success rate was 82.1 % without difference between the success rate of the duodenoscope and the single-balloon enteroscope. Overall adverse event rate was 10.5 %: 6.1 % duodenoscope,10.7 % single-balloon enteroscope, 33.3 % paediatric colonoscope. The duodenoscope allowed all conventional ERCP procedures, whereas the singleballoon enteroscope required dedicated ERCP catheters and did not allow metallic stent placement. However, the single-balloon enteroscope facilitated access to the papilla and sphincteroplasty allowed direct cholangioscopy. ERCP indications were bile duct stones (53.7 %), cholangitis (20.9 %), chronic pancreatitis (20.9 %), pancreatic cancer (1.5 %) and liver transplantation (3%). Therapeutic ERCP success rate is high in patients with Billroth II gastrectomy using either a conventional duodenoscope or the single-balloon enteroscope, with an acceptable and comparable adverse event rate. The choice of endoscope may depend on local experience, post-operative anatomy and therapeutic indication., (© Acta Gastro-Enterologica Belgica.)

Background and Study Aims: Small bowel ulceration poses a limited, but difficult differential diagnosis. The most common causes are Crohn's disease (CD), NSAID-associated enteritis, lymphoma, cytomegaly virus infection and tuberculosis. A less known and relatively novel differential diagnosis is cryptogenic multifocal ulcerative stenosing enteritis (CMUSE)., Patients and Methods: ive patients referred for balloon-assisted enteroscopy for various reasons showed endoscopic features of CMUSE. These findings and, when available, medical imaging were reviewed in order to increase general knowledge on CMUSE., Results: Five patients, 3 males and 2 females, with a mean age of 39±5 years, underwent balloon-assisted enteroscopy. Typical short, circular, ulcerative stenoses were detected in the jejunum in 2 and in the ileum in 3 patients. The number of stenoses ranged from 1 to 7 per patient. Histopathology revealed nonspecific granulocyte inflammation without specific CD findings. Stenoses were often missed on pre-enteroscopy CT or MRI enteroclysis due to their short length. Treatment consisted of endoscopic balloon dilation in 3, corticosteroids in 3, azathioprine in 1 and anti-TNFα biologicals in 3 patients. 3 patients needed additional surgery because of ongoing symptomatic small bowel stenosis or retained wireless videocapsule., Conclusion: In patients with short, ulcerative small intestinal stenoses CMUSE is an important but often neglected differential diagnosis. The pathophysiology and relationship to CD are subject of ongoing debate, but specific endoscopic characteristics, different histopathological findings and lack of clear abnormalities on CT or MRI enterography suggest that CMUSE is a distinct albeit rare chronic inflammatory bowel disease., (© Acta Gastro-Enterologica Belgica.)

Ulcerative colitis and Crohn's diseases are relapsing longstanding inflammatory bowel diseases, associated with an increased risk of developing colorectal cancer. Continuous surveillance is necessary to detect the preneoplastic lesions in an early stage. New endoscopic techniques have improved the diagnostic accuracy and have resulted in a new and more simplified classification system of the dysplastic lesions in the bowel. Histopathologically these lesions are very heterogenous, consisting of adenomatous, villous and the more recently discovered serrated dysplasia. Its diagnosis may be hampered by the inflamed mucosa, resulting in a high interobserver variability in the categories of indefinite for dysplasia and low-grade dysplasia. Therefore the ECCO guidelines recommend to confirm the diagnosis of dysplasia by a pathologist with expertise in gastrointestinal pathology. In this article we give an overview of colitis-associated dysplasia from the point of view of the endoscopist and the pathologist., (© Acta Gastro-Enterologica Belgica.)

Three cases of basal cell carcinoma in Crohn's disease patients treated with azathioprine are described. A review of the literature is conducted concerning this association between the occurrence of basal cell carcinoma and the use of azathioprine. Recently, practical advice on screening and follow-up of these situations have been proposed but there are no validated dermatological recommendations., (© Acta Gastro-Enterologica Belgica.)

Colonoscopy is an important endoscopic examination for the diagnosis and treatment of pathological conditions of the colon, like polyps and colorectal cancer. However, several factors determine the quality of colonoscopy and thus the quality of polyp and colorectal cancer detection. The Flemish Society of Gastroenterology (VVGE) performed a voluntary on-line registry among its members to identify quality of colonoscopy in Flanders, Belgium. 64 gastroenterologists voluntarily registered 4276 consecutive colonoscopies performed during a 3 month study period. Colonoscopy quality indicators were prospectively collected and analysed. Results showed a low voluntary participation rate (17%), acceptable overall adenoma detection rate of 20,5% and colorectal cancer interval rate of 5,4%. Complications were low (perforation 0,1% and major bleeding 1,5%). The current study showed that in Flanders, Belgium on-line registration of colonoscopy quality indicators is feasible and that quality of colonoscopy in daily practice meets the expectations of (inter)national guidelines. However, further improvement of the registry and an open debate on the quality control of colonoscopy in Flanders is warranted (Belgian Registry B30020096548)., (Copyright© Acta Gastro-Enterologica Belgica.)

Background and Study Aims: Animal models of colitis are widely used to study the pathogenesis of inflammatory bowel diseases (IBD) and irritable bowel syndrome (IBS). However techniques allowing sequential assessment of colonic inflammation over time, without the need to sacrifice the animal, are required. This study evaluated in vive colonoscopy to follow the evolution of colitis in rats in comparison with the more commonly used post-mortem macroscopic, microscopic and biochemical assays of inflammation., Methods: Colitis was induced in rats by a single intrarectal instillation of trinitrobenzene sulphonic acid (TNBS). Using a baby upper gastrointestinal endoscope, the severity of colitis was monitored at days 3, 10, 28 and 56 after the induction of colitis. Inflammation was scored by colonoscopy based on the degree of ulceration, extent of inflammation, mucosal bleeding, oedema and stenosis. During follow-up, rats were randomly selected for postmortem macroscopic and microscopic histology and myeloperoxidase (MPO) assessment of the colon., Results: Colonoscopy showed signs of severe mucosal inflammation in the distal colon 3 days after induction of TNBS colitis. Subsequently, colitis subsided at days 10 and 28 with complete endoscopic remission at day 56. During the acute phase of inflammation, endoscopic findings were consistent with the post-mortem inflammatory parameters (macroscopic and microscopic histopathology, MPO colonic activity). A strong correlation between endoscopy and macroscopy remained even during the chronic phase of inflammation., Conclusions: Our findings suggest that routine endoscopy is a reliable method for monitoring the development and follow-up of the degree of TNBS colitis in rats.

In an era of increasing use of immunomodulator (IM) therapy, opportunistic infections have emerged as a pivotal safety issue in patients with inflammatory bowel disease (IBD). Today's challenge to the physician is not only to manage IBD, but also to recognise, prevent and treat common and uncommon infections. The recent European ECCO guidelines on the management and prevention of opportunistic infections in patients with IBD provide clinicians with guidance on the prevention, detection and management of opportunistic infections in patients with IBD. Proposals may appear radical, potentially changing current practice, but we believe that the recommendations will help optimise patient outcomes by reducing morbidity and mortality related to opportunistic infections in patients with IBD. In this ongoing process, prevention is far the first and most important step. Prevention of opportunistic infections relies on recognition of risk factors for infection, the use of primary or secondary chemoprophylaxis, careful monitoring (clinical and laboratory work-up) before and during the use of immunomodulators, vaccination and education of the patient. Special recommendations should also be given to patients before travel. Additionally, this paper discusses how the ECCO guidelines can be implemented in Belgium according to reimbursement legislation.

The small bowel has gained new attention since the development of the wireless videocapsule in 2000, opening up the last 'black box' of the gastrointestinal tract. Although conventional push enteroscopy has been available for decades, since the wireless videocapsule new enteroscopes have been developed to examine the entire small bowel endoscopically in order to perform all conventional endoscopic procedures. The present review highlights the historic evolution of enteroscopy, from the first complete enteroscopy in 1971 over the current balloon-assisted and over-tube-guided methods of enteroscopy to future directions of evolutions towards perfection.

As population-wide screening for colorectal cancer is adopted by many western countries for all individuals aged 50-75. The success of screening colonoscopy programs is highly dependent on the quality of the procedures. High-quality complete endoscopy with excellent patient preparation and adequate withdrawal time is necessary for effectively reducing colon cancer risk. In Belgium formal quality assurance programs and principles of credentialing do not exist. The current reimbursement system for colonoscopy does not reward a careful performed examination but rapidly performed examinations at unnecessarily short intervals. There is a clear need for evidence-based quality measures to ensure the quality of screening colonoscopy. In this guideline review we present an overview of the literature concerning criteria for best practice and important quality indicators for colonoscopy. A summary of the latest guidelines is given. Our goal of this update is to provide practical guidelines for endoscopists performing screening colonoscopy. We hope to provide a broad consensus and an increasing adherence to these recommendations.