Annals of Gastroenterology

Consensus statements of the Hellenic Autoimmune Liver Diseases Study Group on the diagnosis and current management of primary biliary cholangitis

2026-04-01T12:28:50+03:00

Primary biliary cholangitis (PBC) is an autoimmune epithelitis of small intrahepatic bile ducts that affects predominately females, and is characterized by chronic cholestasis, circulating PBCrelated autoantibodies, and progressive disease at the histological level. Key manifestations include pruritus, fatigue, hyperpigmentation, dry-gland syndrome, xanthelasmas and frequent concurrent extrahepatic autoimmune diseases, although approximately half the patients are nowadays completely asymptomatic at diagnosis. The current Consensus Statements of the Hellenic Autoimmune Liver Diseases Study Group aim to provide updated and practical statements to clinicians for PBC diagnosis and management. The presence of antimitochondrial antibodies is a key diagnostic marker for PBC. PBC-specific antinuclear antibodies (anti-gp210 and anti-sp100) also bear diagnostic and prognostic significance. Following diagnosis, this document provides guidance on the comprehensive assessment and risk stratification of patients, using demographic factors, clinical and biochemical laboratory findings, liver autoimmune serology and fibrosis stage. After 6-12 months of therapy with first-line treatment (13-15 mg/kg/day ursodeoxycholic acid [UDCA]), a new risk-stratification procedure should be performed, based on the assessment of biochemical response using a continuous scoring system (either GLOBE or UK-PBC score). In non-responders, add-on treatment to UDCA with a second-line agent, a proliferator-activated receptor agonist (PPAR), either elafibranor (PPARα/δ agonist) or seladelpar (PPARδ agonist), is recommended. The treatment target—also known as deep response—should aim to achieve bilirubin within the normal range, specifically at values <0.6× upper limit of normal, along with normalization of alkaline phosphatase. The disease-associated major symptoms (pruritus, fatigue and cognitive dysfunction) should also be promptly recognized and managed in a holistic manner, as they negatively affect the patient’s health-related quality of life.

Keywords Primary biliary cholangitis, ursodeoxycholic acid, antimitochondrial antibodies, elafibranor, seladelpar

Ann Gastroenterol 2026; 39 (2): 123-160

Expert recommendations regarding the use of fecal calprotectin in daily clinical practice: statements of a taskforce process from the Hellenic Group for the Study of Inflammatory Bowel Disease (EOMIFNE)

2026-04-01T12:28:50+03:00

Fecal calprotectin (FC) has become an indispensable tool in everyday clinical practice for the diagnosis and management of inflammatory bowel disease (IBD). Nonetheless, specific and clear recommendations for its use are scarce. On behalf of the Hellenic Group for the Study of IBD (EOMIFNE), a group of experts have formulated 18 statements with the aim to provide evidence for the best use of FC and offer practical guidance in common clinical scenarios. Statements address issues for the proper application of FC measurement in the diagnostic workup of patients with gastrointestinal symptoms, and as a screening tool for the management of established IBD, including pediatric patients. Thus, the present manuscript aims to propose a standardized approach for the optimal use of FC in patient care, also taking into account non-medical concerns.

Keywords Fecal calprotectin, inflammatory bowel disease, EOMIFNE, guidelines

Ann Gastroenterol 2026; 39 (2): 161-173

Impact of pediatric gastrointestinal disorders on learning and cognitive development in schoolchildren

2026-04-01T12:28:50+03:00

Schoolchildren nowadays encounter multiple challenges within the teaching process. Learning disabilities (LD) are characterized as complex conditions that affect academic achievement and cognitive performance. LD are typically linked to neurodevelopmental and genetic factors. However, emerging evidence suggests they may be associated with gastrointestinal (GI) pathologies, including celiac disease, inflammatory bowel disease, irritable bowel syndrome, gastroesophageal reflux disease and Helicobacter pylori infection. The aforementioned GI disorders have been (indirectly) linked with a spectrum of outcomes, such as school functioning, attention regulation, fatigue, and broader cognitive and psychosocial development. The gut-brain axis enacts a crucial role in both cognition and behavior. Furthermore, functional GI disorders may also coexist with somatic symptom anxiety, including school refusal and hypervigilance to bodily sensations. A typical paradigm is emetophobia, an intense fear of vomit, which might result in food avoidance, social withdrawal or even academic disengagement. Moreover, iron and vitamin deficiencies, as manifestation of a malabsorption due to GI diseases, might impact concentration and memory. Additionally, sleep disturbances, chronic discomfort and psychological stress could deteriorate cognitive and educational functioning. This work reviews current evidence linking GI health to LD and related neurodevelopmental/psychological outcomes. Timely diagnosis and treatment, targeting both GI and psychological factors, might improve cognitive outcomes and learning potential in schoolchildren with LD. Future studies with longitudinal and interventional designs are warranted, in order to elucidate any causal relationships and to determine whether targeted treatment of GI disorders leads to objective improvement in learning and cognitive outcomes.

Keywords Schoolchildren, learning disabilities, gastrointestinal pathologies, irritable bowel syndrome, functional dyspepsia

Ann Gastroenterol 2026; 39 (2): 174-183

Glucagonoma of the pancreas: diagnostic approach and therapeutic algorithm for a rare nosological entity

2026-04-01T12:28:51+03:00

Glucagonoma remains a very rare neuroendocrine tumor of the pancreas, accounting for 2% of all islet-cell carcinomas. The aim of this review is to highlight important aspects of pancreatic glucagonoma, including epidemiology, clinical presentation and diagnostic evaluation, and to elucidate the current therapeutic management of this nosologic entity. A combined automated and manual systematic search of the literature was performed using electronic search engines (Medline/ PubMed, Scopus, Ovid and Cochrane Library), until April 2025. Glucagonoma originates from the a-cells of the pancreatic Langerhans islets. Its reported incidence is 1 in 20,000,000 per year. Typical clinical manifestations include necrolytic migratory erythema, diabetes mellitus (DM), weight loss and anemia, along with elevated serum glucagon levels. Other symptoms, such as venous thrombosis, neuropsychiatric findings known as 4D (dermatitis, DM, deep-vein thrombosis, depression), or diarrhea can also be present. Unfortunately, metastases are encountered in the majority of patients. Prompt diagnosis is usually accomplished by computed tomography and magnetic resonance imaging. The only treatment option is the surgical resection of the tumor. Conservative management, based on the administration of chemotherapy, somatostatin analogs, molecular targeted therapy and peptide receptor radionuclide therapy is also an alternative.

Keywords Glucagonoma, pancreas, therapeutic management, prognostic parameters

Ann Gastroenterol 2026; 39 (2): 184-190

Determinants of the healthy gut microbiome: core features, modifying factors and normal functions

2026-04-01T12:28:51+03:00

The human gut microbiome represents a complex and dynamic ecosystem that is central to maintaining health and preventing disease. Defining a “normal” gut microbiome remains challenging, given the significant variability arising from host physiology, lifestyle, genetics, geography and environmental exposures. This review synthesizes current evidence regarding the composition and functions of the gut microbiota in healthy individuals from diverse populations. At the taxonomic level, healthy gut microbial communities are typically dominated by the phyla Firmicutes and Bacteroidetes, with additional contributions from Actinobacteria and Proteobacteria. However, substantial inter-individual and regional differences are observed, such as a higher prevalence of Prevotella in populations consuming fiber-rich Eastern diets, and greater Bacteroides abundance in Western cohorts. Anatomical location and health status also influence alpha-diversity, underscoring the need to interpret diversity metrics within context. Furthermore, the gut microbiome performs essential functional roles across multiple organ systems, including fermentation of dietary fibers into short-chain fatty acids, regulation of immune responses, modulation of the gut-brain axis, maintenance of intestinal barrier integrity, and support of cardiovascular and hepatic functions. These findings support the conceptualization of the microbiome as a multifunctional organ system that integrates host and environmental signals. In summary, a healthy gut microbiome is best understood as a dynamic equilibrium, characterized by functional resilience and adaptability, rather than a fixed microbial profile. Interpreting this variability is crucial for developing targeted interventions to prevent disease.

Κeywords Microbiome, alpha-diversity, gut microbiota, healthy, normal gut

Ann Gastroenterol 2026; 39 (2): 191-201

Prevalence and risk factors of subclinical hepatic encephalopathy in patients with cirrhosis

2026-04-01T12:28:51+03:00

Background Subclinical hepatic encephalopathy (SHE) is considered an early stage of clinical encephalopathy and has been associated with shortened lifespan and increased healthcareassociated burden. We aimed to assess the prevalence of SHE in patients with cirrhosis and to elucidate the potential factors related to its occurrence.

Methods Thirty consecutive patients with cirrhosis were evaluated between March and July 2017. The exclusion criteria included overt hepatic encephalopathy, recent gastrointestinal hemorrhage, neurological disease, and the use of lactulose or non-absorbable antibiotics. After exclusion, 23 patients were included in this study. Twenty healthy age- and sex-matched controls were also included. SHE was assessed using the number connection test (NCT) and the inhibitory control test (ICT).

Results The NCT completion time was significantly longer in cirrhotic patients than in controls (77±45 vs. 27±6 sec, P<0.001), with 78.3% of cirrhotic patients showing abnormal results. ICT correct target recognition was also significantly lower in cirrhotic patients (18.5±21.8% vs. 56.2±15.8%, P<0.001), with 60.9% showing abnormal results. By combining NCT and ICT, 39.1% of patients with cirrhosis were diagnosed with SHE. No significant associations were detected between the Child-Turcotte-Pugh class or baseline parameters and the presence of SHE. At the 3-month follow up, the SHE diagnosis remained consistent, with 66.7% of those diagnosed at baseline still exhibiting SHE.

Conclusions SHE is prevalent in patients with cirrhosis and significantly affects cognitive and psychomotor abilities. Although the study sample was small, these findings highlight the necessity of regular psychometric testing in cirrhotic patients to identify and manage SHE.

Keywords Subclinical hepatic encephalopathy, cirrhosis, prevalence, risk factors

Ann Gastroenterol 2026; 39 (2): 202-207

Geographic distribution and demographic patterns of primary biliary cholangitis and autoimmune hepatitis in Colombia: a national population-based administrative study (2018-2024)

2026-04-01T12:28:51+03:00

Background Autoimmune liver diseases, including primary biliary cholangitis (PBC) and autoimmune hepatitis (AIH), are rare chronic conditions with significant morbidity. However, population-based epidemiological data from Latin America remain limited. This study aimed to describe the geographic distribution and demographic patterns of PBC and AIH in Colombia between 2018 and 2024.

Methods A descriptive, cross-sectional population-based study was conducted using data from the Comprehensive Social Protection Information System (SISPRO) of the Colombian Ministry of Health. Individuals with at least 1 recorded diagnosis coded as K74.3 (PBC) or K75.4 (AIH) according to the International Classification of Diseases, 10th Revision (ICD-10), were identified. Administrative prevalence estimates were calculated per 100,000 population, using official population projections from the National Administrative Department of Statistics (DANE). Age- and sex-specific distributions were analyzed, and geographic variation was visualized using choropleth maps at the regional level.

Results A total of 6504 PBC cases and 11,225 AIH cases were identified. The estimated national administrative prevalence was 14.7 per 100,000 population for PBC and 17.0 per 100,000 for AIH. Both conditions showed marked female predominance. PBC was more frequent in women aged 50-69 years. However, AIH demonstrated a broader age distribution, affecting individuals from young adulthood to older age. Higher prevalence estimates were observed in multiple northern regions, particularly in the Caribbean region.

Conclusions This first nationwide administrative assessment of PBC and AIH in Colombia demonstrates marked sex differences and regional variation, highlighting the need to improve diagnostic awareness and strengthen epidemiological surveillance of autoimmune liver diseases in Latin America.

Keywords Primary biliary cholangitis, autoimmune hepatitis, epidemiology, administrative prevalence, Colombia

Ann Gastroenterol 2026; 39 (2): 208-213

Long-term outcome after endoscopic ultrasound-guided pancreatic duct drainage

2026-04-01T12:28:51+03:00

Background Obstruction of the main pancreatic duct (MPD) may result in severe pain, recurrent pancreatitis, and pancreatic insufficiency. Endoscopic retrograde cholangiopancreatography (ERCP) with pancreatic duct cannulation and stent placement is the standard first-line approach, yet it sometimes fails or is not feasible. Endoscopic ultrasound-guided pancreatic duct drainage (EUS-PDD) has emerged as a surgical alternative. We assessed the long-term outcomes, safety, and technical aspects of EUS-PDD.

Methods We retrospectively reviewed all adult patients who underwent EUS-PDD at a tertiary referral center between April 2016 and November 2022. Only patients who underwent pancreatogastrostomy or pancreatojejunostomy and had at least 12 months of follow up were included. Clinical success was defined as a residual visual analog scale score ≤2 without obstructive pancreatitis recurrence. Adverse events, reinterventions, and long-term outcomes were analyzed.

Results Thirty-five patients (mean age 58±11 years; 74% male) were included, with a mean follow up of 23±19 months. Chronic pancreatitis accounted for 54% of indications. Technical success was achieved in all patients. Overall clinical success was 80% (95% confidence interval [CI] 64-91%). Adverse events occurred in 17% (95%CI 7-33%), including severe events in 6%. Reintervention was required in 29% of patients, mainly because of stent dysfunction. During follow up, 26% experienced pancreatitis, most commonly related to stent dysfunction. Two deaths occurred, unrelated to pancreatic disease or the procedure.

Conclusion EUS-guided pancreatic duct drainage is a safe and effective long-term treatment option in selected patients with MPD obstruction or disruption when ERCP is not feasible, providing durable symptom control with acceptable morbidity.

Keywords Endoscopic ultrasound-guided pancreatic duct drainage, endoscopic retrograde cholangiopancreatography, pancreatic duct cannulation, stent placement

Ann Gastroenterol 2026; 39 (2): 214-220

Association between SIRT1 rs3758391 genetic variant and susceptibility to pancreatic and gastric cancer

2026-04-01T12:28:52+03:00

Background The SIRT1 gene encodes a NAD⁺-dependent deacetylase that regulates apoptosis, metabolism and genomic stability through interaction with p53 and other transcription factors. Functional single nucleotide polymorphisms within SIRT1 may alter gene expression and affect cancer susceptibility. The rs3758391 and rs369274325 polymorphisms have been implicated in various malignancies; however, their role in pancreatic and gastric cancer remains unclear.

Methods This case-control study included 94 patients with pancreatic ductal adenocarcinoma (PDAC), 38 patients with gastric cancer (GC), and 74 healthy controls, all of Greek origin. Genomic DNA was extracted from peripheral blood samples. Genotyping was performed by RFLP-PCR for rs3758391 and tetra-primer ARMS-PCR for rs369274325. Genotype and allele frequencies were compared using χ2 test and odds ratios (ORs) with 95% confidence intervals (CIs).

Results A significant association was identified between SIRT1 rs3758391 and PDAC and GC susceptibility. The TT genotype was overrepresented among PDAC patients, while the TC genotype conferred a protective effect against both PDAC (P=0.0039; OR 0.35, 95%CI 0.17-0.62) and GC (P=0.0059; OR 0.26, 95%CI 0.10-0.66). The C allele was more frequent in healthy controls compared to PDAC patients (P<0.001; OR 0.39, 95%CI 0.25-0.62). No significant association was observed for rs369274325 in either cancer type or with clinicopathological parameters.

Conclusions This is the first study to evaluate SIRT1 genetic variants in PDAC and GC. The rs3758391 polymorphism appears to influence susceptibility to both malignancies, potentially via altered p53-mediated regulation of SIRT1. These findings suggest SIRT1 as a candidate biomarker for gastrointestinal cancer risk, meriting further validation in larger, ethnically diverse cohorts.

Keywords SIRT1, rs3758391, rs369274325, pancreatic ductal adenocarcinoma, gastric cancer

Ann Gastroenterol 2026; 39 (2): 221-227

Efficacy of current therapeutic strategies for immune checkpoint inhibitor-related esophagitis

2026-04-01T12:28:52+03:00

Background Immune checkpoint inhibitor-related esophagitis (IME) is often managed with proton pump inhibitors (PPIs). Severe or refractory cases may require steroids and/or selective immunosuppressive therapies (SIT). However, large-scale studies assessing IME treatment strategies are lacking. This study evaluated their efficacy.

Method This retrospective study at a tertiary cancer center included patients with malignancy who received immune checkpoint inhibitor (ICIs) from 2010-2024 and developed IME, defined as new or worsening upper gastrointestinal (GI) symptoms post-ICI initiation with other causes excluded.

Results Among 148 patients, 75% received PD-1/PD-L1 inhibitors for 4.9 months; 50.7% received concurrent chemotherapy. Isolated IME was present in 27.7% of patients, while the remainder had concurrent immune-mediated GI conditions. Only 24.4% of isolated IME cases were treated with PPIs, and there was no significant difference between the PPI and non-PPI groups in steroid administration, outcomes or recurrence. Corticosteroids were used in 27.7% of cases, significantly shortening the time to symptom resolution (12 vs. 45 days; P=0.015). Nausea (87.8% vs. 57%, P<0.001) and emesis (58.5% vs. 34.6%, P=0.008) were more frequently observed in the steroid group, along with higher rates of hospitalization (73.2% vs. 36.4%, P<0.001), need for intravenous steroids (30% vs. 0%, P<0.001), and ICI discontinuation (74.4% vs. 44.6%, P=0.002). SIT were required for other concomitant GI adverse events in 41.5% of the steroid-treated patients. No significant differences in clinical improvement, ICI resumption or all-cause mortality were noted between the corticosteroid and non-corticosteroid groups.

Conclusion Our findings showed faster clinical improvement with steroids, while PPIs demonstrated no significant effectiveness.

Keywords Immune checkpoint inhibitors, proton pump inhibitors, corticosteroids, budesonide, immune checkpoint inhibitor-related esophagitis

Ann Gastroenterol 2026; 39 (2): 228-237

Gaps in the diagnosis of small bowel adenocarcinoma among patients with Crohn’s disease: a tertiary care perspective

2026-04-01T12:28:52+03:00

Background Small bowel adenocarcinoma (SBA) is a rare and serious complication of Crohn’s disease (CD), with symptoms often mimicking CD-related symptoms. Therefore, preoperative diagnosis of SBA is difficult, since conventional imaging is rarely diagnostic. This study aims to evaluate the utility of imaging and endoscopic modalities in detecting SBA among patients with CD.

Methods A retrospective review of medical records from a multi-institutional tertiary care center was conducted. ICD-10 codes were used to identify patients with CD who were diagnosed with SBA between January 1, 2019, and November 24, 2024.

Results Of 92 patients identified, 36 met the inclusion criteria. Twenty-one (58.3%) were male, and 35 (97.2%) were Caucasian. The median age at SBA diagnosis was 61 years, with a median 19-year interval from initial CD diagnosis to SBA diagnosis. Thirty-one patients (86.1%) had preoperative imaging, but only 7/31 (22.6%) had findings that raised concern for malignancy. Eight (22.2%) of the patients who underwent endoscopy were diagnosed with SBA or dysplasia on endoscopic biopsy; 18 cases were discovered incidentally during surgery. Sixteen patients (44.4%) had stage III or IV cancer at diagnosis, and 18 patients (50.0%) achieved oncologic remission.

Conclusions Among patients with CD diagnosed with SBA, a large proportion of imaging and endoscopic studies failed to suggest malignancy. Given the substantial proportion of patients diagnosed at advanced stages, and the associated poor outcomes, a high index of suspicion and multimodal evaluation could improve the diagnostic yield in long-standing CD patients with new or changing symptoms.

Keywords Small bowel adenocarcinoma, Crohn’s disease, inflammatory bowel disease, small bowel cancer, gastrointestinal malignancy

Ann Gastroenterol 2026; 39 (2): 238-246

Machine learning in predicting treatment response and remission in inflammatory bowel disease: a systematic review

2026-04-01T12:28:52+03:00

Background The heterogeneity of inflammatory bowel disease (IBD) and its unpredictable course
have always been a challenge for gastroenterologists, with regard to predicting the disease response
using endoscopic techniques. Machine learning (ML) models have shown some early promise in
predicting treatment response in IBD patients.

Methods We conducted a systematic review of studies investigating the application of ML to
predict treatment response and remission in IBD patients. We used the CHARMS checklist for
data extraction. Bias was assessed with the PROBAST tool.

Results We included in our review 6 studies that evaluated numbers of IBD patients ranging from
67 to 3004. ML models demonstrated low to moderate predictive accuracy for treatment response
and remission (area under the receiver operating characteristic curve: 0.489-0.811; sensitivity:
0.46-0.96; specificity: 0.56-0.98). The studies that utilized ML models with more input variables
performed better. Furthermore, only 2 studies performed external validation, and half of the
studies demonstrated a substantial risk of bias due to missing data/overfitting, and variability in
outcome definition

Conclusions ML models show considerable promise in predicting treatment outcomes and
remission in IBD. However, given the substantial bias in studies so far, future studies should use a
standardized methodology, external validation, and an interpretable broader input variable.

Keywords Machine learning, inflammatory bowel disease, treatment, monitoring, response

Ann Gastroenterol 2026; 39 (2): 247-253

Endoscopic submucosal dissection and submucosal tunneling endoscopic resection of gastric subepithelial lesions originating from the muscle layer: a multicenter retrospective study

2026-04-01T12:28:52+03:00

Background Gastric subepithelial lesions (SELs) from the muscularis propria are usually managed surgically or with surveillance. Advances in endoscopic techniques now permit safe en bloc resection, even for lesions with extraluminal growth, but data from outside East Asia are scarce.

Methods We performed a multicenter retrospective study across 18 centers in Europe, the Middle East, South America and South Asia, including patients with gastric SELs from the muscularis propria resected by endoscopic submucosal dissection (ESD) or submucosal tunneling endoscopic resection (STER) between 2017 and 2024. Outcomes included en bloc resection, safety, complications, and recurrence.

Results Eighty-two patients (62.2% women; median age 59 years) were included. Median lesion size was 2 cm (range 0.6-8). Lesions were located in the cardia (18.3%), fundus (18.3%), body (40.2%), and antrum (23.2%). Histology showed gastrointestinal stromal tumors in 78.0%, leiomyomas in 19.5%, and schwannomas in 2.5%. Most were endoluminal (80.5%), 19.5% were extraluminal, and 7.3% extended beyond the serosa. ESD was performed in 65.9% and STER in 34.1%. Median procedure time was 120 min. Deliberate perforation was performed in 31.7%, while 92.3% were managed endoscopically. En bloc resection was achieved in 96.3%, with defect closure in 90.2%. Complications occurred in 7%, with no mortality. Local relapse occurred in 2.5% after a median 9-month follow up. One-third of procedures took place in non-academic centers.

Conclusions ESD and STER are safe and effective alternatives to surgery or surveillance for gastric SELs from the muscularis propria, including lesions with extraluminal growth. Longterm, comparative studies alongside laparoscopic surgery are warranted.

Keywords Subepithelial lesion, endoscopic submucosal dissection, submucosal tunneling endoscopic resection, gastrointestinal stromal tumor, submucosal tumor

Ann Gastroenterol 2026; 39 (2):254-261

Isolated immune-mediated enteritis in patients treated with immune checkpoint inhibitor therapy

2026-04-01T12:28:53+03:00

Background Immune checkpoint inhibitors (ICIs) commonly cause colitis, but isolated immunemediated enteritis (IMEN) is poorly characterized. This study describes the clinical features, diagnostic findings, and outcomes of IMEN.

Method We retrospectively identified adults with cancer who developed IMEN within one year of ICI initiation, confirmed as duodenitis, ileitis, or both.

Results Among 20,991 ICI-treated patients, 30 (0.143%) developed isolated IMEN. Median age was 69.5 years; 73.3% were male, and 80% white. The most common malignancies were gastrointestinal/hepatobiliary (26.7%) and melanoma (23.3%). Presenting symptoms included nausea (66.7%), diarrhea (53.3%), and vomiting (46.7%); 62.5% of patients with diarrhea had grade ≥2 severity. Disease involved duodenitis plus ileitis in 50%, isolated duodenitis in 30%, and isolated ileitis in 20%. Median fecal calprotectin levels were highest in duodenitis plus ileitis (1335.5 μg/g), followed by ileitis (319 μg/g) and duodenitis (78 μg/g). Endoscopy showed nonulcerative inflammation
in 60% and ulceration in 20%. Hospitalization was longest in duodenitis plus ileitis (median 13.5 days). Corticosteroids were required in 66.7% of ileitis cases; additional immunosuppression was needed in 33.3% of ileitis and 66.7% of duodenitis plus ileitis. Isolated duodenitis improved with supportive therapy alone. Remission occurred in 63.3% overall. ICI therapy was resumed in 12.5%, exclusively in patients with isolated duodenitis. Complications included fistula formation (10%); all-cause mortality was 36.7%.

Conclusions IMEN is a rare but clinically significant ICI-related toxicity. Fecal calprotectin correlates with ileitis severity and not duodenitis, and small-bowel endoscopy facilitates diagnosis and management.

Keywords Immune checkpoint inhibitor, diarrhea, enteritis, duodenitis, ileitis

Ann Gastroenterol 2026; 39 (2): 262-269

Diffusion-weighted imaging increases the diagnostic performance of magnetic resonance imaging in assessing rectal cancer T stage and reduces intra- and interobserver variability

2026-04-01T12:28:53+03:00

Background Accurate preoperative staging is pivotal in guiding rectal cancer treatment, and in particular for selecting appropriate neoadjuvant therapies and surgical approaches. Magnetic resonance imaging (MRI) remains the standard modality for local staging. However, it has some limitations, particularly in tumors at intermediate clinical stages. Recent evidence has shown that incorporating diffusion-weighted imaging (DWI) can improve diagnostic performance, although its role in T staging has not been completely elucidated.

Methods The diagnostic performance of conventional MRI alone vs. MRI plus DWI in rectal cancer staging was retrospectively evaluated. The correlation between preoperative MRI findings and postoperative histopathological staging was examined. Intra- and interobserver agreement among radiologists with various levels of experience were assessed, both with and without DWI.

Results DWI-MRI improved staging accuracy, particularly for T2 and T3 tumors. The sensitivity and specificity for T2 staging increased from 68% and 96% (MRI alone) to 91% and 98% (DWIMRI), respectively, while the sensitivity and specificity for T3 staging improved from 91% to 97%, and from 78% to 92%, respectively. The intraobserver agreement increased from 90.60% to 94.02% in experienced readers, and from 81.2% to 87.18% in less experienced ones. The interobserver agreement for DWI-MRI increased from 83.76% to 88.03%.

Conclusions DWI-MRI can enhance the accuracy of rectal cancer T staging, particularly when assessing rectal wall invasion, and it reduces overstaging. Moreover, it improves diagnostic consistency among radiologists, regardless of experience. Hence, the routine integration of DWI into preoperative MRI protocols can optimize clinical decision-making and treatment planning.

Keywords Rectal cancer, magnetic resonance imaging, diffusion weighted imaging, preoperative imaging, observer variation

Ann Gastroenterol 2026; 39 (2): 270-276

Optimizing the prioritization of cholangioscopy-guided electrohydraulic lithotripsy: the role of stone characteristics and cost-efficacy

2026-04-01T12:28:53+03:00

Author’s reply

2026-04-01T12:28:53+03:00

Impact of Helicobacter pylori eradication on the progression of Correa’s cascade

2026-04-01T12:28:53+03:00

Authors’ reply

2026-04-01T12:28:53+03:00