Gastroenterol. Insights, Volume 17, Issue 3 (September 2026) – 12 articles

Background/Objective: Enhanced recovery after surgery (ERAS) is a global surgical quality improvement initiative that aims to improve perioperative care based on evidence-based interventions. Although ERAS protocols in gastrointestinal (GI) surgery result in improved patient outcomes, there are variations in protocol adherence and important gaps in understanding the barriers and enablers influencing this adherence. The objective of this scoping review was to map evidence from the relevant literature to identify the barriers and enablers influencing adherence to ERAS protocols in GI surgery. Method: Using the preferred reporting items for systematic reviews and meta-analyses flow diagram, we searched the databases and identified 45 published studies. Results: The scoping review identified staff, patient, and organizational-level barriers and enablers influencing adherence to ERAS protocols. The staff-reported barriers were (1) resistance to practice change, (2) workforce constraints and organizational barriers, (3) interdepartmental coordination barriers, (4) technical barriers, and (5) contextual barriers. The staff-reported enablers were (1) communication and coordination between teams, (2) professional education and a supportive practice environment, and (3) technology-driven patient education. The patient-reported barriers were (1) educational barriers, (2) workforce and clinical barriers, and (3) digital literacy and usability barriers. The patient-reported enablers were (1) patient-centered care and empowerment and (2) multifaceted patient education and delivery. Additionally, this review identified limited resources in smaller hospitals as an organizational-level barrier, whereas participation in national hospital collaborations and ERAS-dedicated hospital status were identified as organizational-level enablers of ERAS protocol adherence. Conclusions: Identifying the determinants of ERAS adherence as barriers and enablers allows healthcare teams to tailor interventions to individual patient needs, promoting greater compliance and improving the effectiveness of ERAS in GI surgery. Full article

Background/Objectives: Pancreatic metastases are uncommon and may resemble primary pancreatic neoplasms on imaging, making tissue confirmation essential. This study aimed to characterize pancreatic metastases diagnosed by endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) and to describe tissue adequacy within the confirmed cohort and procedure-related adverse events. Methods: This retrospective, single-center study included 21 patients with histologically confirmed pancreatic metastases diagnosed by EUS-FNB between January 2021 and November 2025. Clinical data, EUS features, procedural parameters, histopathological findings, management, and outcomes were reviewed. Results: The mean age was 60.9 ± 12.9 years, and 57.1% of patients were male. Lung carcinoma was the most frequent primary tumor (33.3%), followed by renal cell carcinoma (19.0%). Most lesions were solitary (66.7%) and hypoechoic (85.7%). All 21 patients included in the final cohort had histologically adequate EUS-FNB specimens; this finding reflects the selected cohort of confirmed metastatic cases and should not be interpreted as an overall adequacy rate or measure of diagnostic performance. The mean number of needle passes was 1.14 ± 0.36. One small, asymptomatic intrapancreatic hematoma occurred and resolved conservatively. Three selected patients underwent surgical resection and were alive without evidence of disease at last follow-up; however, no inference regarding a survival benefit from surgery can be made from this small, selected subgroup. Conclusions: In this cohort of histologically confirmed pancreatic metastases, EUS-FNB provided tissue suitable for pathological characterization, with immunohistochemical analysis performed when required to determine tumor origin. The present study was not designed to estimate overall diagnostic accuracy or adequacy. Surgical resection may be considered in carefully selected patients with isolated disease, as supported by the published literature; however, the present cohort does not permit assessment of a survival benefit associated with surgery. Full article

Pancreato-hepatobiliary (HPB) malignancies—pancreatic ductal adenocarcinoma (PDAC), hepatocellular carcinoma (HCC), and the biliary tract cancers (BTC) comprising intrahepatic, perihilar and distal cholangiocarcinoma, gallbladder carcinoma, and ampullary adenocarcinoma—together constitute one of the heaviest and fastest-growing burdens in global oncology. Liver cancer is the third leading cause of cancer death worldwide, and pancreatic cancer, with a mortality-to-incidence ratio approaching unity, is projected to become the second leading cause of cancer death in high-income countries. This narrative review synthesises PubMed-indexed evidence across the full clinical arc of all three disease families, organised around epidemiology and risk; diagnosis, staging and biomarkers; surgical and multimodal management; and the rapidly evolving systemic therapy landscape, with survival and prognosis integrated throughout. Three cross-cutting narratives emerge. First, HPB cancers are united by late presentation, biological aggressiveness, and dependence on a background of organ dysfunction (cirrhosis in HCC, biliary obstruction in BTC and PDAC, and chronic pancreatitis as a major predisposing background in PDAC) that constrains therapy. Second, their trajectories are diverging: HCC has achieved the largest proportional survival gain of any solid tumour, driven by surveillance and immunotherapy in the subset of patients who reach specialist care; BTC has entered a nascent precision-oncology era in which FGFR2, IDH1, HER2, and BRAF alterations are druggable and immune-chemotherapy is first-line standard, although absolute survival gains remain modest and access to comprehensive molecular profiling is uneven; whereas PDAC has improved only incrementally, its immunosuppressive stroma and near-universal KRAS driver remaining formidable barriers. Third, molecular profiling, multidisciplinary care, and surgical centralisation are now non-negotiable structural determinants of outcome. We conclude that HPB oncology has entered a phase of real but unevenly distributed progress: long-term survival remains poor for most patients globally, and translating these advances into population-level gains will require earlier detection, broader access to molecular profiling and novel therapies, and biology-driven innovation. Full article

Background: Gastrointestinal (GI) involvement is increasingly recognised in paediatric SARS-CoV-2 infection and multisystem inflammatory syndrome in children (MIS-C), but severe GI bleeding remains rare. Its pathogenesis in this setting is multifactorial: direct viral injury, hyperinflammatory microvascular damage, treatment-related mucosal injury, and coagulopathy may all contribute, and the relative role of each is often difficult to disentangle. Case Presentation: A previously healthy 12-year-old boy underwent appendectomy for perforated appendicitis with peritonitis. On postoperative Day 1, he developed high fever and was found to be SARS-CoV-2 PCR-positive; SARS-CoV-2 IgM and IgG were also positive. He met the positive clinical elements of the CDC 2023 case definition for MIS-C (persistent fever, multisystem involvement—gastrointestinal, hepatic, haematological, and markedly elevated inflammatory markers), although perforated appendicitis with peritonitis is a sufficient alternative explanation and the diagnosis cannot be regarded as secure (see Discussion). Treatment included broad-spectrum antibiotics (meropenem, amikacin, metronidazole), methylprednisolone 2 mg/kg/day, and intravenous immunoglobulin (IVIG) 2 g/kg. On Day 4 in the paediatric intensive care unit (PICU), the patient developed sudden haematemesis with fresh blood through the nasogastric tube and haemodynamic collapse. Coagulation studies revealed prolonged INR (1.6) and reduced prothrombin activity (42%). The patient was stabilised with packed red blood cells, fresh frozen plasma, and intravenous vitamin K. Fibrogastroscopy demonstrated diffuse mucosal bleeding without ulcers or anatomical defects; histology showed mucosal hyperaemia, mixed basal inflammation with intraepithelial lymphocytes, and small erosions. Melena persisted for several days. The child recovered fully and was discharged after 20 days with substantially improved but not fully normalised laboratory values (residual mild anaemia, Hb 110 g/L, and elevated CRP 32.7 mg/L and D-dimer 5.88 mg/L). Conclusions: Severe upper GI bleeding is a rare but life-threatening event in children with severe SARS-CoV-2 infection and MIS-C. In our case, several mechanisms may have acted in combination, although none could be confirmed individually: possible direct viral enterocyte injury via ACE-2 receptors, hyperinflammatory microangiopathy, high-dose corticosteroid-related mucosal injury, possible broad-spectrum antibiotic-associated vitamin K deficiency, and postoperative critical-illness stress. Their relative contributions cannot be determined from a single retrospective case. Bleeding occurred despite continuous PPI prophylaxis, suggesting that PPI cover alone is insufficient when multiple risk factors coexist; the clinical implication is that risk-factor-based (rather than universal) PPI prophylaxis, together with monitoring of vitamin K-dependent coagulation, should be considered in critically ill children receiving high-dose corticosteroids and prolonged broad-spectrum antibiotics. Full article

Background/Objectives: Although the exact etiology of Inflammatory Bowel Diseases (IBD) is not yet fully understood, recent evidence suggests that both genetic and dietary factors are involved in their pathogenesis. The aim of the present exploratory study was to investigate how first-degree relatives (FDRs) of individuals with IBD perceive familial risk and the role of diet in IBD onset and prevention. Methods: A mixed methods approach was followed. A total of 103 unaffected FDRs of individuals living with IBD in Greece participated in an online questionnaire examining demographic characteristics, disease-related knowledge, risk perception, and beliefs about the role of diet in IBD. In parallel, 16 semi-structured interviews explored participants’ beliefs, self-reported dietary practices, and the factors shaping them using a framework analysis guided by the Health Belief Model. Results: Exploratory quantitative findings indicated that belief in the role of diet was associated with higher odds of self-reported family dietary changes, while belief in genetic risk was associated with lower odds of self-reported family dietary changes. The findings did not characterize the nature, maintenance, or motivation of these changes. Qualitative findings provided a deeper understanding of participants’ beliefs, highlighting that diet was mainly viewed as relevant to IBD management rather than prevention. Fear of disease onset and healthcare professional guidance were perceived as key facilitators of dietary changes. Conclusions: Our findings highlight heterogeneous beliefs regarding familial IBD risk and self-reported family diet changes, and support future research addressing balanced familial-risk communication for unaffected FDRs. Full article

Ulcerative colitis affects millions of people worldwide, and acute severe ulcerative colitis (ASUC) remains one of its most urgent presentations because delayed recognition of steroid non-response can expose patients to colectomy, postoperative complications, and prolonged hospitalization. The Truelove and Witts (T&W) criteria, first published in 1955, remain historically important because they provide a simple bedside definition of severe disease and continue to inform admission thresholds in contemporary practice. This opinion article argues that the T&W criteria should be retained as an entry definition for classic ASUC but should no longer be used as a standalone framework for dynamic risk stratification or treatment escalation. Modern guidelines and consensus statements increasingly supplement clinical toxicity with C-reactive protein (CRP), albumin, fecal calprotectin, validated endoscopic scores, intestinal ultrasound, and early prognostic indices. These tools do not replace bedside assessment; rather, they help clinicians identify steroid non-response and inflammatory burden before systemic toxicity alone becomes decisive. A balanced interpretation is therefore required: the T&W criteria remain useful because they are simple, familiar, and globally applicable, but they are insufficient by themselves for treat-to-target decision-making. Future ASUC severity classifications should integrate traditional clinical assessment with objective biomarkers, endoscopic findings, imaging, and prospective validation across both resource-rich and resource-limited settings. Full article

Background: The intake of mineral water for therapeutic purposes (crenotherapy) in digestive system disorders is a long-established practice, but there are still few controlled clinical studies confirming the effects of natural mineral water rich in bicarbonate. Objective: To verify whether the daily intake of Aqua 3 bicarbonate natural mineral water is able to improve digestion in a population of patients with functional dyspepsia and gastroesophageal reflux disease symptoms. Methods: Patients with a diagnosis of functional dyspepsia, formulated in accordance with the Rome IV criteria, were subjected to three 2-week intake periods: a tap water period (wash-out), a bicarbonate natural mineral water period, and an oligomineral water period. The mineral water bottles were anonymized by removing the identifying labels. The primary efficacy endpoint was the change in the Patient Assessment of Upper Gastrointestinal Disorders–Symptom Severity Index (PAGI-SYM) total score. The secondary endpoints were: improvements in the PAGI-SYM subscale scores, the use of antacids, and the self-assessment of efficacy of digestion. Power analysis indicated that a minimum of 48 pairs were required and, to ensure adequate sample size, 50 subjects were enrolled. Results: The PAGI-SYM total score and the six subscale scores significantly decreased after bicarbonate mineral water intake and significantly increased after oligomineral water supplementation. During the bicarbonate mineral water period, antacid use decreased significantly, with nine patients discontinuing antacid medication (p = 0.004). During the subsequent oligomineral water period, antacid use increased, with seven patients requiring new antacid administration, although this increase did not reach statistical significance (p = 0.070). The comparison between changes observed during the bicarbonate and oligomineral water periods was significant (p = 0.005). In addition, the scores of the patients’ subjective assessments of the effectiveness of their digestion were significantly better after the intake of bicarbonate water than after intake of oligomineral water. Conclusions: In line with the evidence reported in the literature, the preliminary findings suggest that the intake of Aqua 3 bicarbonate mineral water may alleviate dyspeptic and reflux-related symptoms and improve digestive effectiveness in patients with functional dyspepsia. Given the exploratory design, small sample size, and fixed treatment sequence, these results should be interpreted as hypothesis-generating and require confirmation in adequately powered randomized controlled trials. The intake of Aqua 3 bicarbonate mineral water proved to be a simple, safe, and natural intervention capable of improving digestive symptoms in patients with functional dyspepsia and reflux-related disorders while promoting the digestive process. Full article

Background and Objectives: This study aimed to characterize physicians’ knowledge and practice patterns regarding the use of probiotics in the management of irritable bowel syndrome (IBS). By examining clinical experiences and barriers to adoption, this research sought to identify critical gaps in practice and establish a foundation for evidence-based improvements in patient care. Materials and Methods: The survey was conducted in accordance with the CROSS (Consensus-based Checklist for Reporting of Survey Studies) guidelines. Attendees of a medical congress, specifically general practitioners, gastroenterologists, surgeons, and internists with an interest in the clinical significance and therapeutic modulation of the human microbiome, were invited to participate. Participants completed a 38-item, paper-based questionnaire. The instrument assessed respondents’ self-perceived knowledge of probiotics, their understanding of probiotic definitions and specific strains, and their current clinical practice patterns—particularly regarding the management of irritable bowel syndrome (IBS). Additionally, the survey explored information sources, the frequency of self-prescription, and the perceived need for further education, with a specific focus on safety profiles and clinical concerns. Results: Of the 70 invited attendees, 68 completed the survey, yielding a response rate of 97.1%. The respondent cohort included 40 general practitioners (GPs), 20 gastroenterologists (GEs), four surgeons (SSs), and four internists (SIMs). More than half of the respondents were female (n = 37, 54.4%), with a median age of 43 years (range: 28–70). Exactly half of the respondents (n = 34, 50.0%) agreed that probiotics always have a role in the management of irritable bowel syndrome (IBS); however, only 44.1% (n = 30) reported familiarity with the relevant scientific literature on probiotics. Furthermore, respondents more frequently recognized bacterial species associated with single-strain probiotic formulations compared to those in multi-strain mixtures. The primary concern regarding the administration of probiotics for IBS was this lack of familiarity with the scientific literature, cited by 23.5% of respondents. Notably, 100% of the surveyed cohort expressed a need for further education on the topic. Conclusions: The emergence of scientific and clinical evidence results in a clinical practice characterized by high prescribing habits, despite the lack of formal approval. These findings highlight evidence showing the effectiveness of certain probiotic strains in managing IBS symptoms, suggesting the need for standardized guidelines. Given the demonstrated need for further education among the surveyed cohort, integrating probiotic-specific training into both undergraduate medical curricula and continuing professional development programs could significantly enhance the clinical knowledge and awareness of both current and future practitioners. Full article

Hepatobiliary disorders during pregnancy represent a significant cause of maternal and fetal morbidity, requiring careful differentiation between physiological adaptations of pregnancy and true hepatic pathology. This narrative review provides a comprehensive overview of three major hepatobiliary conditions encountered during pregnancy: gallstone disease, intrahepatic cholestasis of pregnancy (ICP), and viral hepatitis (HAV, HBV, HCV, HDV, and HEV). Pregnancy-induced hormonal and immunological changes influence disease pathogenesis, clinical presentation, diagnostic interpretation, and therapeutic decision-making. Gallstone disease remains the most common non-obstetric surgical condition in pregnancy, with contemporary evidence supporting timely laparoscopic intervention when indicated. ICP is characterized by pruritus and elevated serum bile acids and is associated with increased risks of preterm birth, fetal distress, and stillbirth, necessitating close surveillance and individualized delivery planning. Viral hepatitis poses unique challenges because of the potential for vertical transmission, maternal complications, and adverse neonatal outcomes. Universal antenatal screening for hepatitis B and C is increasingly recognized as a cornerstone of care. For HBV, maternal antiviral prophylaxis combined with neonatal immunoprophylaxis has reduced mother-to-child transmission to below 1%, whereas the role of direct-acting antivirals for HCV during pregnancy continues to evolve. HEV remains the most severe viral hepatitis in pregnancy, carrying disproportionately high maternal mortality in endemic regions. Across all conditions, multidisciplinary management involving hepatologists, gastroenterologists, obstetricians, maternal–fetal medicine specialists, surgeons, and neonatologists is essential to optimize outcomes. This review synthesizes current evidence, highlights pregnancy-specific diagnostic and therapeutic considerations, and identifies emerging areas of research that may further improve maternal and neonatal outcomes. Full article

Introduction: Gastrointestinal bleeding (GIB) is a potentially life-threatening condition associated with significant morbidity, mortality, and healthcare burden. While endoscopy remains the first-line method of management, transarterial embolization (TAE) plays an important role where endoscopic therapy fails or is not feasible. Aim: The aim of this study was to evaluate the demographics, etiologies, management patterns, and reintervention rates of patients with GIB undergoing angiography and TAE. Methods: This retrospective study included 43 patients who underwent angiography for GIB. Patients were stratified as upper (UGIB) or lower GIB (LGIB). Descriptive statistics were used to summarize demographics, clinical characteristics, pre-procedural investigations, interventions, and outcomes. Results: Of the 43 patients (mean age 58.9 ± 17.9 years), 62.8% had UGIB and 37.2% had LGIB. Pre-procedural evaluation was performed in 97.7% of patients, including CT scans (88.4%) and endoscopy (67.4%). Embolization was performed in 76.7% of cases, including prophylactic (39.5%) and therapeutic (32.6%) approaches. Of the patients with contrast extravasation on CT, 66.7% underwent embolization, with 64.3% of these patients requiring no further intervention. Within 30 days, 18.6% of all patients who underwent angiography required endoscopic reintervention, 16.3% required surgery, and 7.0% died due to ongoing/recurrent bleeding. Complications were infrequent, including acute kidney injury (2.3%) and access site hematoma (4.7%). Conclusions: Angiography with TAE is a valuable and broadly safe intervention for GIB refractory to endoscopic management. Despite a moderate rate of reintervention, it provides effective hemorrhage control in a substantial proportion of patients. Further studies are required to identify predictors of clinical success and optimize patient selection. Full article

Background: Irritable bowel syndrome (IBS) is a chronic disorder of brain–gut interaction closely linked to psychological stress and highly prevalent among university student populations, yet data from Bahrain remain scarce. This study estimated the frequency of self-reported IBS-like symptoms among university students in Bahrain and examined their associations with sex, age, qualification level, body mass index (BMI), psychological stress, and lifestyle behaviors. Methods: A cross-sectional, online questionnaire-based survey was conducted among 310 students at the University of Bahrain in October 2021. A self-administered 16-item instrument, based on the Rome III symptom domains and used as a symptom-screening rather than a diagnostic tool (face validity only; no formal psychometric validation was performed), assessed sociodemographic characteristics, self-reported IBS-like symptoms, stress and anxiety, and lifestyle behaviors. Data were analyzed using chi-square tests and one-way ANOVA; effect sizes were quantified using Cramér’s V (chi-square) and partial eta-squared (η², ANOVA); the significance threshold was α = 0.05 (two-tailed). Results: Self-reported IBS-like symptoms were common: 52.9% (95% CI 47.3–58.4) reported recurrent abdominal pain, 58.1% (95% CI 52.5–63.4) abdominal bloating, and 80.3% (95% CI 75.5–84.4) reported interference with academic activities. Most participants perceived their mental state (84.8%) and examinations (73.2%) to worsen symptoms, yet only 48.7% correctly identified IBS. Exploratory subgroup analyses suggested differences by qualification level, with diploma-level students reporting higher rates of abdominal pain (p < 0.001; Cramér’s V = 0.22), bloating (p < 0.05; Cramér’s V = 0.13), and perceived psychological impact on symptom severity (p < 0.001; Cramér’s V = 0.19) compared with bachelor- and master-level counterparts. The substantial female over-representation (79%) precluded formal sex-based inference; all findings should be interpreted in this context. Conclusions: Self-reported IBS-like symptoms were commonly endorsed, and participants frequently perceived psychological stress to worsen symptoms. Diploma-level students may represent a previously unrecognized potentially at-risk subgroup warranting further investigation and, if confirmed, targeted stress-focused health-promotion strategies, particularly through brief psychoeducation modules integrated within diploma-program curricula, and dedicated prospective research. Future studies should incorporate validated Rome IV diagnostic criteria, multivariable regression modeling, and biomarker assessment to elucidate underlying brain–gut mechanisms. Full article

Background: Colorectal cancer (CRC) remains a significant global health challenge, particularly because of its associated complications. Among these, tumor perforation is a critical event linked to increased postoperative morbidity and mortality. This study aimed to evaluate and compare the surgical outcomes of patients with perforated colon cancer versus those with non-perforated colon cancer. Methods: A retrospective comparative study was conducted in the visceral surgery departments of Hassan II University Hospital in Fes, Morocco, including 198 patients who underwent surgical treatment for colon cancer between January 2014 and December 2022. Statistical analyses included descriptive assessments and comparative tests using the Chi-square and Student’s t-tests, with a p-value < 0.05 considered statistically significant. Results: Of the 198 patients, 22 (11%) presented with perforated colon cancer. Laparotomy was the predominant surgical approach in the perforated group (86.4%), whereas laparoscopy was more frequently used in non-perforated cases (56.2%, p = 0.001). Stoma creation was significantly more common in perforated cases (72.7% vs. 4%, p < 0.001), with a notably higher rate of stoma closure failure in the perforated group (37.5% vs. 0%, p < 0.001). Postoperative complications were also more frequent in the perforated group (36.4% vs. 13.6%, p = 0.006), with higher rates of R2 resections (27.3% vs. 0.6%, p < 0.001) and tumor recurrence (27.3% vs. 4.5%, p < 0.001). The mean hospital stay was significantly longer in patients with perforated cancer (11 days vs. 5 days, p < 0.001). Conclusions: This comparative study demonstrates that patients with perforated colon cancer are more likely to require a Hartmann’s procedure, to have prolonged intensive care unit stays, to experience higher rates of postoperative complications, to undergo R2 resections, and to have a greater incidence of tumor recurrence. A non-significant trend toward higher 30-day mortality was also observed. Full article