Pancreatic steatosis is a strong risk factor for post-ERCP pancreatitis: An emerging concept.

OBJECTIVE: The Endoscopic Retrograde Cholangiopancreatography (ERCP) is the treatment of choice for biliary obstruction but is associated with post-ERCP pancreatitis (PEP) in around 5 % of cases. No radiological criteria have been evaluated for predicting PEP risk. DESIGN: This retrospective study examined records of 1365 patients who underwent ERCP at our center between 2014-2023. Only sphincterotomy-naïve patients were included. CT scans within 30 days of ERCP were reviewed for radiological criteria. The optimal pancreatic density cut-off was determined using AUROC and Youden index. Logistic regression was used for analyses. RESULTS: PEP occurred in 75 patients (6.1 %). The CT scan was performed before ERCP for 565 of the total population. A fatty pancreas, defined as a spontaneous density less than -50HU, was statistically associated with PEP (OR: 7.35; 95 % CI: 1.56-26.5 p = 0.004), as well as with biliary obstruction due to stones (OR: 0.61; 95 % CI: 0.38-0.98; P = 0.04), the need for precut (OR: 2.19; 95 % CI: 1.35-3.51; P = 0.001), cannulation of the main pancreatic duct (OR: 2.23; 95 % CI: 1.36-3.59; P = 0.001), and the use of a pancreatic stent (OR: 2.48; 95 % CI: 1.29-4.47; P = 0.004). In multivariate analyses, only obstruction unrelated to gallstones (OR = 2.63; 95 % CI: 1.16-6.25; P = 0.024) and a low pancreatic density (<-50HU) (OR=7.94, 95 %CI: 1.59-31.09; P = 0.005) remains significantly associated with the risk of PEP, including after adjustment for age and sex (P = 0.006). CONCLUSION: A very low pancreatic fat density could be a significant risk factor for post-ERCP pancreatitis with potential clinical and research implications. Further validation is needed.

Optimized sequential therapy vs 10- and 14-d concomitant therapy for eradicating Helicobacter pylori: A randomized clinical trial.

BACKGROUND: A cure for Helicobacter pylori (H. pylori) remains a problem of global concern. The prevalence of antimicrobial resistance is widely rising and becoming a challenging issue worldwide. Optimizing sequential therapy seems to be one of the most attractive strategies in terms of efficacy, tolerability and cost. The most common sequential therapy consists of a dual therapy [proton-pump inhibitors (PPIs) and amoxicillin] for the first period (5 to 7 d), followed by a triple therapy for the second period (PPI, clarithromycin and metronidazole). PPIs play a key role in maintaining a gastric pH at a level that allows an optimal efficacy of antibiotics, hence the idea of using new generation molecules. AIM: To compare an optimized sequential therapy with the standard non-bismuth quadruple therapies of 10 and 14 d, in terms of efficacy, incidence of adverse effects (AEs) and cost. METHODS: This open-label prospective study randomized 328 patients with confirmed H. pylori infection into three groups (1:1:1): The first group received quadruple therapy consisting of twice-daily (bid) omeprazole 20 mg, amoxicillin 1 g, clarithromycin 500 mg and metronidazole 500 mg for 10 d (QT-10), the second group received a 14 d quadruple therapy following the same regimen (QT-14), and the third group received an optimized sequential therapy consisting of bid rabeprazole 20 mg plus amoxicillin 1 g for 7 d, followed by bid rabeprazole 20 mg, clarithromycin 500 mg and metronidazole 500 mg for the next 7 d (OST-14). AEs were recorded throughout the study, and the H. pylori eradication rate was determined 4 to 6 wk after the end of treatment, using the 13C urea breath test. RESULTS: In the intention-to-treat and per-protocol analysis, the eradication rate was higher in the OST-14 group compared to the QT-10 group: (93.5%, 85.5% P = 0.04) and (96.2%, 89.5% P = 0.03) respectively. However, there was no statistically significant difference in eradication rates between the OST-14 and QT-14 groups: (93.5%, 91.8% P = 0.34) and (96.2%, 94.4% P = 0.35), respectively. The overall incidence of AEs was significantly lower in the OST-14 group (P = 0.01). Furthermore, OST-14 was the most cost-effective among the three groups. CONCLUSION: The optimized 14-d sequential therapy is a safe and effective alternative. Its eradication rate is comparable to that of the 14-d concomitant therapy while causing fewer AEs and allowing a gain in terms of cost.

Prevalence of small intestinal bacterial overgrowth in irritable bowel syndrome (IBS): Correlating H2 or CH4 production with severity of IBS.

Background and Aim: The prevalence and the role of small intestinal bacterial overgrowth (SIBO) in irritable bowel syndrome (IBS) remain unclear, as the literature provides heterogeneous information on the subject. The aim of this study was to determine the prevalence of SIBO in IBS and to assess the correlation between methane and hydrogen levels measured during breath tests and the severity of IBS. Method: Two-hundred and forty-seven patients with IBS were prospectively included. A glucose breath test (GBT) measured H2 and CH4 production to diagnose SIBO. A test was positive when H2 values exceeded 12 ppm in the first 90 min and/or when a CH4 value exceeded 10 ppm at any time. IBS severity (IBS-SSS), quality of life (GIQLI), and anxiety and depression (HAD) were assessed to investigate the correlation with H2 and CH4 production. Results: The prevalence of SIBO in IBS was 36.4% (9.7% with H2, 26.7% with CH4). CH4 levels were significantly higher in the predominantly constipated patients (P = 0.00), while H2 levels were significantly higher within the diarrheal phenotype (P = 0.01). IBS severity was not correlated with either H2 levels (r = 0.02; P = 0.84) or CH4 levels (r = 0.05; P = 0.64). H2 production was inversely correlated with the quality of life (r = -0.24; P = 0.03) and significantly correlated with the HAD scale (r = 0.22; P = 0.03). The pain and discomfort experienced during GBT was not correlated with methane levels (r = -0.09, P = 0.40), hydrogen levels (r = -0.01, P = 0.93), or sum of both (r = 0.06, P = 0.58), but significantly associated with IBS severity (r = 0.50, P <0.00). Conclusion: SIBO has a high prevalence in IBS but does not increase its severity. Individual susceptibility to pain may have a greater influence on the severity of IBS.

Can the microbiota predict response to systemic cancer therapy, surgical outcomes, and survival? The answer is in the gut.

INTRODUCTION: The gut microbiota seems to play a key role in tumorigenesis, across various hallmarks of cancer. Recent evidence suggests its potential use as a biomarker predicting drug response and adding prognostic information, generally in the context of immuno-oncology. AREAS COVERED: In this review, we focus on the modulating effects of gut microbiota dysbiosis on various anticancer molecules used in practice, including cytotoxic and immune-modulating agents, primarily immune-checkpoint inhibitors (ICI). Pubmed/Medline-based literature search was conducted to find potential original studies that discuss gut microbiota as a prognostic and predictive biomarker for cancer therapy. We also looked at the US ClinicalTrials.gov website to find additional studies particularly ongoing human clinical trials. EXPERT COMMENTARY: Sequencing of stool-derived materials and tissue samples from cancer patients and animal models has shown a significant enrichment of various bacteria such as Fusobacterium nucleatum and Bacteroides fragilis were associated with resistant disease and poorer outcomes. Gut microbiota was also found to be associated with surgical outcomes and seems to play a significant role in anastomotic leak (ATL) after surgery mainly by collagen breakdown. However, this research field is just at the beginning and the current findings are not yet ready to change clinical practice.

Saccharomyces boulardii CNCM I-745 plus sequential therapy for Helicobacter pylori infections: a randomized, open-label trial.

AIM: To determine the effect of Saccharomyces boulardii CNCM I-745 (S. boulardii) plus sequential therapy on Helicobacter pylori (H. pylori) eradication rate. METHODS: This open-label prospective study randomized (1:1) patients with confirmed H. pylori infection to standard sequential therapy of twice-daily (bid) omeprazole 20 mg plus amoxicillin 1 g for 5 days, followed by bid omeprazole 20 mg, clarithromycin 500 mg and metronidazole 500 mg for the next 5 days (control group), or sequential therapy plus bid S. boulardii 250 mg (experimental group). Adverse events (AEs) were recorded throughout the study, and the H. pylori eradication rate was determined 4 weeks after treatment. RESULTS: The study was conducted from May 2013 to May 2016 and included 199 patients (51.3% male; mean age 44.6 ± 13.6 years). The H. pylori eradication rate was higher in the experimental group than the control group (86.0% vs. 74.7%; P = 0.02). Compared with the control group, patients in the experimental group experienced a significantly lower overall incidence of AEs (17.0% vs. 55.7%; p < 0.001) and the incidence of antibiotic-associated diarrhea (2.0% vs. 46.4%; P = 0.02). The experimental group showed improved treatment compliance over the 10-day study period compared with the control group (95.0% vs. 91.2%, P < 0.001). CONCLUSION: Addition of S. boulardii to sequential therapy improved H. pylori eradication rate and reduced the incidence of treatment-associated AEs in Moroccan patients with H. pylori infection.