Endoscopic procedures are the cornerstone of intervention in gastroenterology—from evaluating common illnesses to non-surgically managing complex diseases. Expectedly, these procedures are linked to greenhouse gas (GHG) emissions globally and contribute significantly to the global climate change crisis. Professional gastroenterology societies globally raise awareness of this evolving crisis and suggest specific measures to appropriately measure the burden contributed by endoscopy units and mitigate the environmental impact of this common clinical practice. To the unsuspecting eye, the solution to this crisis is relatively simple: decrease the utilization of endoscopic procedures. However, the dependence of modern medicine on these procedures, both diagnostically and therapeutically, makes it significantly more challenging to reduce their utilization. Instead, a structured approach to systematically consider the specific indications for each procedure, minimize waste generation, promote recycling of waste products, and limit the number of repeat endoscopies until clinically necessary may be more pragmatic to reduce GHG emissions globally. In this narrative review, we discuss the perspectives of global gastroenterology societies on sustainable or “green” endoscopy and summarize their recommendations to aid the day-to-day gastroenterologist in making their contribution to environmental sustainability while providing optimal care to their patients.

Background We sought to identify systemic factors influencing door-to-puncture times (DTP) among patients with pre-arrival notifications presenting directly to a comprehensive stroke center (CSC) and undergoing emergent mechanical thrombectomy (MT). Methods In this retrospective analysis of a prospectively maintained registry of acute ischemic stroke (AIS) patients undergoing MT at two CSCs between January 2021 and October 2023, we included consecutive AIS patients presenting directly to the CSC with pre-arrival notifications via emergency medical services (EMS) and who underwent emergent MT. We excluded patients with known confounders to DTP and divided this cohort into two groups: DTP ≤75 min and >75 min. We used variables with P value 75 min, adjusting for door-to-CT time. Results Of 900 patients, 605 were inter-facility transfers, 89 were excluded due to known confounders/missing prehospital notifications, leaving 206 qualifying patients. On multivariable analysis, not meeting American Heart Association (AHA) level 1 criteria (adjusted OR (aOR) 3.04, 95% CI 1.62 to 5.82, P75 min DTP times. Most patients (62.3%) had no clearly documented reasons for delay in MT, whereas 25.8% of delays were attributed to prolonged medical decision-making. Conclusion Arrival outside business hours, not meeting AHA level 1 criteria, and lack of PSSS acquisition by EMS were associated with prolonged DTP. Impacting modifiable factors such as prehospital assessment of stroke severity is an optimal target for quality improvement.

Background: Colonoscopy remains the gold standard for colorectal cancer screening. Deep learning systems with real-time computer-aided polyp detection (CADe) demonstrate high accuracy in controlled research settings and preliminary randomized controlled trials (RCTs) report favorable outcomes in clinical settings. This study aims to evaluate the efficacy of AI-assisted colonoscopy compared to standard colonoscopy focusing on Polyp Detection Rate (PDR) and Adenoma Detection Rate (ADR), and to explore their implications for clinical practice. Methods: A systematic search was conducted using multiple indexing databases for RCTs comparing AI-assisted to standard colonoscopy. Random-effect models were utilized to calculate pooled odds ratios (ORs) with 95% confidence intervals. The risk of bias was assessed using the Cochrane Risk of Bias Tool, and heterogeneity was quantified using I statistics. Results: From 22,762 studies, 12 RCTs (n = 11,267) met the inclusion criteria. AI-assisted colonoscopy significantly improved PDR (OR 1.31, 95% CI 1.08–1.59, p = 0.005), despite heterogeneity among studies (I² = 79%). While ADR showed improvement with AI-assisted colonoscopy (OR 1.24, 95% CI, 0.98–1.58, p = 0.08), the result was not statistically significant and had high heterogeneity (I² = 81%). Conclusions: AI-assisted colonoscopy significantly enhances PDR, highlighting its potential role in colorectal cancer screening programs. However, while an improvement in the ADR was observed, the results were not statistically significant and showed considerable variability. These findings highlight the promise of AI in improving diagnostic accuracy but also point to the need for further research to better understand its impact on meaningful clinical outcomes.

Heart failure with preserved ejection fraction (HFpEF) represents the predominant form of heart failure, affecting over 50% of all heart failure patients with increasing prevalence in aging populations. Despite significant advances in cardiovascular medicine, HFpEF remains a complex clinical syndrome with poorly understood pathophysiology and limited treatment options. While most studies have traditionally focused on the renin–angiotensin–aldosterone system (RAAS) and other related mechanisms, emerging evidence has unveiled a critical bidirectional relationship between dysregulation of gut microbiota and HFpEF development. This phenomenon, mediated through microbiome-driven inflammation and endothelial dysfunction, introduces a novel concept and potential emerging conceptual framework in understanding HFpEF. This comprehensive review explores this novel gut–heart axis by synthesizing the latest evidence from original studies and clinical trials. We discuss novel mechanisms involving bacterial metabolites, including short-chain fatty acids (SCFAs), trimethylamine N-oxide (TMAO), bile acids, and amino acid derivatives. We also examine how gut dysbiosis may contribute to systemic inflammation through lipopolysaccharide translocation, NLRP3 inflammasome activation, and endothelial dysfunction. Furthermore, clinical trials investigating microbiome-targeted interventions, including probiotics, fecal microbiota transplantation, metabolite supplementation, and precision medicine approaches, are critically evaluated for their therapeutic potential. This review provides a framework for hypothesis generation and future research directions about therapeutic strategies targeting the gut–heart axis in HFpEF management.

INTRODUCTION: Stercoral colitis is the inflammation of the colon due to impacted feces or fecaloma. Fecaloma is a firm organized mass due to prolonged presence of residual fecal material. Stercoral colitis has rare incidence, most common demographics being elderly, chronic opioid users, patients with limited mobility and intellectual disability. Risk factors include abnormal anatomical and physiological conditions affecting environment and function of colon. Complications include perforation, bowel ischemia, septic shock, respiratory failure, multiorgan dysfunction. DESCRIPTION: 18-y.o. female with past medical history of Lennox-Gastaut syndrome, chronic constipation presented to the ED with inconsolable crying, pointing towards her abdomen and assuming fetal position as she is nonverbal at baseline. The patient was hypotensive and tachycardiac on presentation. Labs showed leukocytosis, lactic acidosis and elevated transaminases. Imaging with CTAP with IV contrast showed rectal fecal impaction and severe colonic stool burden. She did not pass stool even on bowel regimen with senna, miralax, lactulose, and frequent enemas. Her blood pressures dropped significantly requiring initiation of pressors. She was placed on mechanical ventilation for worsening respiratory distress and increased work of breathing. Eventually, she had high grade fever, uptrending leukocytosis, lactic acidosis and worsening respiratory status. Repeat CTAP showed findings of bowel ischemia with pneumatosis in the colon and mesentery of small intestine. Intraopertively, a massive and uniformly distended, Ischemic colon was identified and underwent Subtotal colectomy with rectal stump decompression. DISCUSSION: Fecal impaction due to fecaloma resulting in colonic distention and increased intra-luminal colonic pressure leads to compression of bowel wall. Bowel wall inflammation, edema eventually cause vascular compromise with bowel ischemia, perforation, pressure ulceration and necrosis. Although conservatively managed early in the course, Multidisciplinary team approach in patients who fail to respond to conservative management is important to prevent further complications.

BACKGROUND AND OBJECTIVES: Timing of restarting antiplatelet agents after middle meningeal artery embolization (MMAE) for chronic subdural hematoma (cSDH) is a topic of controversy. The aim of this study was to determine whether the timing of antiplatelet restart after MMAE for cSDH affects long-term radiographic and clinical outcomes. METHODS: A multi-institutional, retrospective cohort study was performed using data from 4 academic medical centers that performed MMAE for cSDH from 2018 to 2023. Patients were prescribed an antiplatelet agent before MMAE were included. Variables included demographics, comorbidities, timing of the procedure and antiplatelet restart, baseline modified Rankin Scale, initial size of SDH, and embolic material used. Outcomes were thickness of SDH at short-term (2 weeks) and long-term (6 weeks) follow-ups, need for unplanned surgical evacuation, and modified Rankin Scale at 90 days. RESULTS: Of 128 patients (78% male, median age 76 years [IQR 70-83]), 67 patients (52%) had their antiplatelet agent restarted postintervention. Patients who did not have their antiplatelet agent restarted experienced higher mortality (20% vs 5%, P = .038). Among patients with antiplatelet agent restarted postintervention, there was a significant correlation (R = −0.43, P = .025) between timing of antiplatelet restart and long-term SDH size change. Antiplatelet restart on postintervention day 3 or later was associated with improvement in long-term SDH thickness (β = −5.7 mm, s.e. 2.5, P = .034). This effect was observed in the particle-embolization subgroup (β = −8.3 mm, s.e. 3.2, P = .021), but not the liquid-embolization subgroup (β = 1.7 mm, s.e. 5.5, P = .773). CONCLUSION: There was a higher rate of mortality and decreased functional independence among patients who did not have their antiplatelet agent restarted after MMAE for cSDH. Among patients who did have their antiplatelet restarted, a restart date of postintervention day 3 or later was associated with a significant decrease in long-term SDH size.