Dr. Michael Wilsey: Endoscopy Pearls and Ergonomics (Part 2)

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Dr. Michael Wilsey gave our group an excellent update on Endoscopy Pearls and Ergonomics. My notes below may contain errors in transcription and in omission. Along with my notes, I have included many of his slides.

Yesterday’s post focused on endoscopy pearls. Today’s post focuses on ergonomics. Most of the attendees realized that we could use a lot of improvement in this area after listening to this presentation. This issue is likely of even greater importance in those with a high endoscopy case load.

  • A high percentage of gastroenterologists/pediatric gastroenterologists develop injuries related to repetitive endoscopy procedures.  These can be mitigated using proper ergonomics.  Although this advice is pretty straight forward, a lot of endoscopists could benefit from careful attention to this.
Areas included neck/upper back (44.0%), thumb (42.0%), hand/finger (38.0%), lower back (36.0%).
  • Keep Monitor near eye level and in front of you (don’t torque your neck)
  • Maintain good posture. Can start by standing upright against a wall
  • Position bed so elbows can be in a fairly neutral position with bed not more than 10 cm below elbows
  • Two-piece lead aprons helpful to distribute weight better
  • Handle endoscope more like holding a pencil than using a firm grip
  • Cushioned mat and cushioned soles can help with standing posture/fatigue

Dr. Michael Wilsey: Endoscopy Pearls and Ergonomics (Part 1)

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Dr. Michael Wilsey gave our group an excellent update on Endoscopy Pearls and Ergonomics. My notes below may contain errors in transcription and in omission. Along with my notes, I have included many of his slides.

Endoscopy Pearls:

  • Video Link to show techniques:
    • YouTube (~6 minute): How to Perform a Water-aided colonoscopy. Sergio Cadoni, Sauid Ishaq, VideoGIE, Volume 3, Issue 5, 2018; Pages 169-170.
    • Residue can be suctioned while infusing more water, which helps to clean the colon, but if there is too much residue, it is very difficult to see clearly enough to insert the colonoscope properly.
    • The water immersion technique starts with the patient in the left lateral position so that the progressive irrigation of water eases down the sigmoid by gravity on the left abdominal quadrant. Instead of syringes, the use of water flushing pumps allows one to better adjust the quantity of water needed according to the morphology of the sigmoid and does not delay the maneuvers of scope progression.
  • Anatomy: sigmoid and transverse colon are more mobile. They are suspended by mesenteries (the transverse mesocolon and sigmoid mesocolon), which allow them to swing or shift freely in the abdomen, unlike the other fixed parts of the colon.

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Optimizing PPI Therapy for Eosinophilic Esophagitis with CYP2C19 Genotyping

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P Bose et al. American Journal of Gastroenterology. DOI: 10.14309/ajg.0000000000004117 Dose May Matter: CYP2C19 Genotype and Proton-Pump Inhibitor Response in Pediatric Eosinophilic Esophagitis

Methods: A cohort study of pooled data from 2 tertiary-care pediatric centers (Riley Children’s Health,Indianapolis, IN, and Children’s Hospital of Philadelphia, Philadelphia, PA) was conducted. N=131, mean age 8.5 yrs. Individuals with certain CYP2C19 polymorphisms were classified as normal (NMs), intermediate/slow(IMs), and rapid metabolizers (RMs) of PPIs based on the presence of normal function (*1), loss-of-function (*2), or gain-of-function (*17) alleles. PPI choice and dosing:

Key findings:

  • PPI response occurred in 22.1% of subjects (29/131)
  • Overall, IMs had the highest proportion of PPI response at 33.3% (10/30), followed by NM of 21.7% (13/60) and RM of 14.6% (6/41) (P 5 0.205).
  • No ultra-rapid metabolizers had a response.

Discussion: “Atypical dosing for PPI use in EoE may be related to mechanisms of action apart from gastric acid suppression, such as inhibiting eosinophil migration or restoring esophageal mucosal barrier integrity, which have been previously proposed.”

There may have been a selection bias in this population. The methods section does not detail these cohorts precisely. It is unclear if all patients in these centers undergo CYP2C19 genotype testing. In most centers, CYP2C19 genotype testing is uncommon and may be more likely in those who have not responded to therapy.

My take:

  1. CYP2C19 genotype testing may help determine whether PPI therapy is likely to work for a patient with EoE and influence the dosage selected. This is not a new concept. It was noted at a NASPGHAN meeting in 2017.
  2. In those with unfavorable CYP2C19 genotype, either an alternative therapy or a PPI that is not metabolized with CYP2C19 (eg. rabeprazole) should be considered.

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AI Diagnosis of Achalasia on Plain Chest X-ray

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T Ochaiai et al. Clin Gastroenterol Hepatol 2026; 24: 2308-2310. Open Access! Artificial Intelligence-Based Detection of Achalasia on Plain Chest Radiography

Methods: This retrospective study collected posteroanterior plain chest radiographs of
patients with and without achalasia. The training and validation datasets comprised 447
chest radiographs taken between January 2017 and March 2023.

Key findings:

  • In the validation dataset, the area under the curve for identifying achalasia was 0.971, and using Youden’s index, the sensitivity, specificity, accuracy, and positive and negative predictive values were 0.950, 0.917, 0.932, 0.905, and 0.957, respectively
  • In the temporal test dataset, the area under the curve for detecting achalasia was 0.964, and using Youden’s index, the sensitivity, specificity, accuracy, and positive and negative predictive values were 0.941, 0.891 , 0.901, 0.696 , and 0.983, respectively.
In Figure F, the CXR corresponds to the findings in the barium esophagogram in G

Discussion:

  • It may help detect patients with early achalasia with mild symptoms who are unlikely to undergo EGD. However, the rarity of the condition may result in many false positives.

My take: In this cohort, AI was developed and validated to detect achalasia on chest radiographs. This is yet another example of how AI can yield additional information from routine testing. Previously, AI has been shown to potentially identify diabetes from routine CXR (Emory News 2023: AI model enables earlier detection of diabetes through chest x-rays).

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Complimentary, Alternative, and Integrative Medical Therapie Use in a Pediatric DGBI Cohort

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A VonAxelson et al. J Pediatr Gastroenterol Nutr. 2026;83:282–284. Patterns in integrative medicine usage among pediatric patients in a disorders of gut–brain interaction clinic

In a retrospective cohort (n=331, mean age 15 years) from a DGBI clinic, the patterns of integrative medicine usage were evaluated. The most common comorbidities in the sample were anxiety (61%), sleep disturbance (36%), and depression (32%). The most common DGBI diagnoses in the study were FD (58%) and IBS (57.4%), with FAP-NOS being third most frequent 10.6%).

Key findings:

  • In total, 59% of patients were receiving some form of integrative treatment
  • Peppermint oil, caraway oil, and acupuncture were the most used in this practice. 

Limitations: “While this study does identify trends in IM strategies for management of DGBI, it is limited by retrospective design, so identifying use of many IM techniques may be underrepresented (ginger, L-glutamine, aloe vera, etc). These might have been used but were not reported or recorded in charts.”

My take: Whatever you want to call it, complementary, alternative or integrative, it is clear that many patients are using non-traditional therapies trying to improve their symptoms. This cohort may have higher use as they are from a specialty multidisciplinary DGBI clinic rather than a general pediatric gastroenterology or general pediatric cohort.

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Discordinate Recommendations for Celiac Screening with Down Syndrome

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VN Dargenio et al. J Pediatr Gastroenterol Nutr. 2026;83:304–313. A systematic review of celiac disease recommendations for children with Down syndrome

Background: “CD [celiac disease] prevalence in DS is higher than in the general population.10 The overlapping symptoms between CD and DS, such as growth failure, fatigue, GI disturbances, and, less frequently, neurological and behavioral problems, pose significant diagnostic challenges, as these are often attributed to underlying DS comorbidities, leading to delays in recognizing CD.4, 11 

Guidelines:

The authors note wide variation in the prevalence of CD in DS in various studies. “A meta-analysis of 31 studies including 4383 individuals found a pooled prevalence of biopsy-confirmed CD of 5.8% (95% CI 4.7%–7.2%), with slightly higher rates in children (6.6%) compared to mixed-age samples (5.1%)31…these findings align with the 5%–13% prevalence range documented in earlier European studies2“

The authors recommend the following strategy:

“Given the high prevalence of asymptomatic and atypical presentations, reliance on symptoms alone is insufficient. A pragmatic strategy should initiate with universal serological screening for all children with DS after gluten introduction (12–24 months of age), followed by periodic re-screening every 2–3 years, using tTG-IgA with total IgA assessment, supplemented by IgG-based assays in the context of the high rate of selective IgA deficiency in DS.”

My take: There are wide discrepancies in the recommendations for screening for celiac disease in asymptomatic individuals with Down syndrome.

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Evaluation of the Rumination Severity Index (RumSI) and Usefulness for Clinical Practice

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JS Khoo, D Yang et al. J Pediatr Gastroenterol Nutr. 2026;83:251–257. The rumination severity index: Development and evaluation of a scoring tool for rumination syndrome

Methods: 66 children with rumination syndrome (RS) completed the 7-item RumSI and PedsQL questionnaires between 2018 and 2023.

RumSI Scoring: Skipped meals, weight loss due to vomiting, and use of a feeding tube or parenteral nutrition were each dichotomized, with absence of the symptom assigned a score of zero for each item and presence of the symptom assigned a score of 1.5σ = 4, where σ is the standard deviation of the combined vomiting/re-swallowing score. Both skipped days of school and social activities in the past 60 days were grouped into categories of 0, 1–4, 5–9, 10–19, 20–39, and 40–60 and assigned integer values of zero to five. The overall RumSI score was calculated by summing the six individual components (vomiting/re-swallowing, skipped meals, weight loss, use of feeding tube or parenteral nutrition, skipped days of school, and skipped days of sports/social activities).

Key Findings:

  • RumSI scores ranged from 0 to 26.5 (mean 10.6 ± 7.2) out of a total possible 28, with higher scores indicating worse rumination symptoms
  • RumSI and PedsQL scores were significantly negatively correlated (r = −0.45, p < 0.001), with every 1-point increase in RumSI score associated with a 1.3-point decrease in PedsQL total score
  • Higher RumSI scores were associated with co-morbid conditions including depression, functional dyspepsia, functional nausea/vomiting, gastroparesis, and postural orthostatic tachycardia syndrome

My take: Currently, the RumSI score would be cumbersome in clinical practice (in the absence of an embedded calculator). However, the questions on the RumSI are very useful and I already made a smartphrase to help capture this information on patients with suspected rumination. Also, the RumSI should be useful for research studies by offering a common scoring system to define and track disease burden.

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Misleading Autoimmune Markers in Wilson Disease Diagnosis

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AS Patel et al. J Pediatr Gastroenterol Nutr. 2026;83:241–246. False positive autoimmune markers and elevated immunoglobulin G in genetically confirmed Wilson disease

Key findings:

  • Elevated IgG (>1.1× upper limit of normal) was observed in 82.3% of WD patients, while 31.5% tested positive for at least one autoantibody
  • 20.2% of WD patients met the simplified diagnostic criteria for AIH
  • Liver histology findings were available in 25 WD patients. Compared to AIH, WD patients were less likely to have interface hepatitis (40% vs. 89%; p < 0.001) and plasma cell infiltrates (32% vs. 72.6%; p = 0.009), while having a higher presence of glycogenated nuclei (24% vs. 6.2%; p = 0.009), ballooning degeneration (56% vs. 33%; p = 0.024), and steatosis (52% vs. 9.8%; p < 0.001). Copper quantification studies were not done

Discussion Points:

  • “Reports of co-existence of WD and AIH in children further complicate the diagnosis.16, 17“
  • “The presence of elevated IgG and autoantibodies, often interpreted as supportive diagnosis of AIH, may be misleading in WD.”

As an aside, I disagree with the authors introduction that “Wilson disease (WD) and autoimmune hepatitis (AIH) are the two most common treatable causes of chronic liver disease (CLD) in children.1, 2” Clearly, steatotic liver disease is the most common treatable chronic liver disease in children; in addition, both hepatitis B and hepatitis C are more common as well.

My take: A low threshold for testing of WD is needed in patients diagnosed with autoimmune hepatitis; this could include genetic testing and/or coppor quantification in liver biopsies..

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Helicobacter pylori Treatment 2026

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T Rokkas, DY Graham. Gastroenterol 2026; 171: 271-284. The Unfinished Agenda in Helicobacter pylori Treatment: Resistance, Microbiome Effects, and Future Directions

This was a narrative review aimed at synthesizing contemporary evidence.

Background: Globally, approximately half of the population is infected. Prevalence surpasses 70% in many low- and middle-income countries (LMICs) where crowded living conditions, poor sanitation, and limited access to clean water enhance transmission. 

Key points:

  • Global resistance to clarithromycin, metronidazole, and fluoroquinolones significantly undermines the performance of traditionally effective antimicrobial therapies. The corner stone of successful antimicrobial therapy is susceptibility-guided therapy but remains of limited use with H pylori because of lack of infrastructure.
  • Clarithromycin should no longer be prescribed as an empiric therapy (ie, it should be restricted to susceptibly based therapy)…Despite the poor cure rates with clarithromycin achieved with vonoprazan in the United States, the American College of Gastroenterology H pylori guideline still recommended vonoprazan triple therapy.17 (With clarithromycin-susceptible infections, vonoprazan is not more effective than PPIs.) The discordance between guideline recommendations and clinical effectiveness contributes to treatment failures.
  • Bismuth quadruple therapy (BQT), which combines metronidazole with tetracycline and bismuth, can partially overcome moderate metronidazole resistance through antimicrobial synergy and higher effective dosing.
  • Next-generation sequencing (NGS) is now available at a fraction of the cost of an endoscopy in the United States using stools, fresh, frozen, or paraffin-embedded gastric biopsies37 (American Molecular). Economic analyses indicate that susceptibility-guided therapy is cost-effective.
  • When BQT fails or is unavailable, several alternative regimens can be considered.4–6 Rifabutin-based triple therapy can achieve eradication rates of 70% to 90% even in heavily pretreated patients.40
  • When designing rescue therapy, antibiotics previously associated with failure should not be reused unless susceptibility has been clearly established.
  • Optimizing H pylori treatment requires evidence-based regimen selection, precision-guided strategies, antimicrobial stewardship, and equitable access to essential medications

My take: This is a helpful review of H pylori issues and management.

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