Helicobacter pylori, gastric microbiota and gastric cancer relationship: Unrolling the tangle.

Helicobacter pylori infection (Hp-I) represents a typical microbial agent intervening in the complex mechanisms of gastric homeostasis by disturbing the balance between the host gastric microbiota and mucosa-related factors, leading to inflammatory changes, dysbiosis and eventually gastric cancer. The normal gastric microbiota shows diversity, with Proteobacteria [Helicobacter pylori (H. pylori) belongs to this family], Firmicutes, Actinobacteria, Bacteroides and Fusobacteria being the most abundant phyla. Most studies indicate that H. pylori has inhibitory effects on the colonization of other bacteria, harboring a lower diversity of them in the stomach. When comparing the healthy with the diseased stomach, there is a change in the composition of the gastric microbiome with increasing abundance of H. pylori (where present) in the gastritis stage, while as the gastric carcinogenesis cascade progresses to gastric cancer, the oral and intestinal-type pathogenic microbial strains predominate. Hp-I creates a premalignant environment of atrophy and intestinal metaplasia and the subsequent alteration in gastric microbiota seems to play a crucial role in gastric tumorigenesis itself. Successful H. pylori eradication is suggested to restore gastric microbiota, at least in primary stages. It is more than clear that Hp-I, gastric microbiota and gastric cancer constitute a challenging tangle and the strong interaction between them makes it difficult to unroll. Future studies are considered of crucial importance to test the complex interaction on the modulation of the gastric microbiota by H. pylori as well as on the relationships between the gastric microbiota and gastric carcinogenesis.

Performance Assessment of Subjects With Nursing Education Trained in Sigmoidoscopy by Means of a Simulator.

Reports evaluating simulation-based sigmoidoscopy training among nurses are scarce. The aim of this prospective nonrandomized study was to assess the performance of nurses in simulated sigmoidoscopy training and the potential impact on their performance of endoscopy unit experience, general professional experience, and skills in manual activities requiring coordinated maneuvers. Forty-four subjects were included: 12 nurses with (Group A) and 14 nurses without endoscopy unit experience (Group B) as well as 18 senior nursing students (Group C). All received simulator training in sigmoidoscopy. Participants were evaluated with respect to predetermined validated metrics. Skills in manual activities requiring coordinated maneuvers were analyzed to draw possible correlations with their performance. The total population required a median number of 5 attempts to achieve all predetermined goals. Groups A and C outperformed Group B regarding the number of attempts needed to achieve the predetermined percentage of visualized mucosa (p = .017, p = .027, respectively). Furthermore, Group A outperformed Group B regarding the predetermined duration of procedure (p = .046). A tendency was observed for fewer attempts needed to achieve the overall successful endoscopy in both Groups A and C compared with Group B. Increased score on playing stringed instruments was associated with decreased total time of procedure (rs = -.34, p = .03) and with decreased number of total attempts for successful endoscopy (rs = -.31, p = .046). This study suggests that training nurses and nursing students in simulated sigmoidoscopy is feasible by means of a proper training program. Experience in endoscopy unit and skills in manual activities have a positive impact on the training process.

Evaluation of the Direct Economic Cost per Eradication Treatment Regimen against Helicobacter pylori Infection in Greece: Do National Health Policy-Makers Need to Care?

Helicobacter pylori (Hp) management has undoubtedly resulted in a notable economic burden on healthcare systems globally, including Greece. Its cost has never been estimated so far, especially during the recent 10-year unprecedented financial crisis. Direct medical and procedural costs for one attempt "outpatient" Hp eradication treatment were estimated as the following: (I) first-line regimens: 10 and 14 days standard triple, 10 and 14 days sequential, 10 and 14 days concomitant non-bismuth quadruple, 14 days hybrid, (II) second-line salvage regimens: 10 and 14 days levofloxacin-containing triple regimens. Treatment costs using prototypes and/or generic drugs were calculated. Drug prices were collected and confirmed from two official online medical databases including all medicines approved by the Greek National Organization for Medicines. Regimens based on generics were more affordable than prototypes and those including pantoprazole yielded the lowest prices (mean: 27.84 €). Paradoxically, 10-day concomitant and 14-day hybrid regimens (currently providing good (90-94%) first-line eradication rates in Greece) cost the same (mean: 34.76 €). The expenditures for Hp eradication treatment regimens were estimated thoroughly for the first time in Greece. These data should be taken into account by Public Health policymakers both in Greece and the European Union, aiming for a better and less expensive therapeutic approach.

Presepsin levels in cirrhotic patients with bacterial infections and/or portal hypertension-related bleeding, presenting with or without acute kidney injury.

BACKGROUND: Bacterial infections in cirrhotic patients remain a challenge. Presepsin has been proposed as a valuable sepsis biomarker. We aimed to assess plasma presepsin levels in uncomplicated cirrhotic patients and to correlate them with liver disease severity and complicating events, defined as documented bacterial infection with or without concomitant portal hypertension-related bleeding, or bleeding without documented bacterial infection, with or without acute kidney injury. METHODS: We prospectively evaluated the presepsin levels of 108 consecutive uncomplicated cirrhotic patients with compensated (55, 50.9%) or decompensated (53, 49.1%) cirrhosis. During the follow up, 20 patients were reevaluated for a complicating event. RESULTS: Mean baseline presepsin levels of the entire population were 440.4 pg/mL. Patients with decompensated cirrhosis exhibited significantly higher baseline levels than patients with compensated cirrhosis (599.1±492.2 vs. 287.5±130.5 pg/mL, P<0.001). In complicated cirrhotic patients, admission levels were remarkably higher than baseline (1438.0±1247.2 vs. 725.3±602.8 pg/mL, P<0.001), especially in those who developed acute kidney injury compared to those who did not (1827.3±1118.8 vs. 1048.7±1302.1 pg/mL, P<0.05). Baseline presepsin levels, using a cutoff of 607.5 pg/mL, could predict liver disease-related 3-month mortality with 77.8% sensitivity and 86.9% specificity: area under the receiver operating characteristic curve 0.825; 95% confidence interval 0.684-0.967; P<0.01. CONCLUSIONS: Plasma presepsin levels are elevated in uncomplicated cirrhotic patients, especially in those with advanced liver disease, and rise further in those complicated by an event. Baseline presepsin levels in cirrhotic patients could be used as an additional marker, along with the model for end-stage liver disease score, to predict short-term outcomes.

Methadone Gastrobezoar in a Psychiatric Patient Presented in Coma.

A 43-year-old psychiatric patient was transferred in coma and hypercapnic respiratory failure at the emergency department. He was intubated for airway protection and transferred to the Intensive Care Unit (ICU). Abdominal X-ray revealed a radiopaque mass; a pharmacobezoar was suspected and confirmed by gastroscopy; one large in the stomach fundus and a smaller one in the pylorus. Gastric lavage through the gastroscope and administration of gastro-kinetic drugs and laxatives were able to dilute the bezoars. Tablets retrieved from the stomach identified as methadone and toxicological tests of the gastric fluid confirmed the presence of methadone as the only organic chemical compound. The patient was extubated on the 7th day and released from the ICU on the 10th day under psychiatric consultation having normal vital signs. Methadone gastric bezoar may lead to persistent intoxication, respiratory failure, and coma requiring ICU care. Diagnosis may be difficult and a high index of suspicion is needed.

Evaluation of four time-saving methods of reading capsule endoscopy videos.

OBJECTIVE: Review of wireless capsule endoscopy recordings is time consuming. The aim of this study was to evaluate four time-saving methods offered with Rapid Software. METHODS: A total of 100 wireless capsule endoscopy videos with abnormal findings were evaluated using five different ways of viewing: (a) manual mode at a speed of 10 frames per second (fps), (b) manual mode at a speed of 20 fps, (c) manual mode with a simultaneous display of two images at a speed of 20 fps, (d) automatic mode at a speed of 10 fps, and (e) quickview mode at a speed of 3 fps. Then, we calculated the concordance of abnormal findings between each one of the four time-saving methods using method A. RESULTS: The mean reading time with time-saving methods was significantly shorter than with method A (method A: 59.8 min, method B: 30 min, method C: 30.2 min, method D: 32.2 min, method E: 16.3 min). The agreement in finding abnormal lesions between method A and the four evaluated methods was excellent and almost perfect (κ>0.8), except for quickview in recognizing polyps. Diagnostic miss rate was 1% for method D, 2% for B and C, and 12% for E. No tumors and cases of celiac or Crohn's disease were lost by all four methods. CONCLUSION: We conclude that manual mode/20 fps, the simultaneous projection of two images/20 fps, and automatic mode/10 fps have minimal diagnostic miss rates and can safely replace slower modes in clinical practice. The quickview mode is a safe diagnostic tool only when larger or diffuse lesions are suspected, such as Crohn's or celiac disease.

Capsule endoscopy image analysis using texture information from various colour models.

Wireless capsule endoscopy (WCE) is a novel imaging technique that is gradually gaining ground as it enables the non-invasive and efficacious visualization of the digestive track, and especially the entire small bowel including its middle part. However, the task of reviewing the vast amount of images produced by a WCE examination is a burden for the physicians. To tackle this major drawback, an innovative scheme for discriminating endoscopic images related to one of the most common intestinal diseases, ulceration, is presented here. This new approach focuses on colour-texture features in order to investigate how the structure information of healthy and abnormal tissue is distributed on RGB, HSV and CIE Lab colour spaces. The WCE images are pre-processed using bidimensional ensemble empirical mode decomposition so as to facilitate differential lacunarity analysis to extract the texture patterns of normal and ulcerous regions. Experimental results demonstrated promising classification performance (mean accuracy>95%), exhibiting a high potential towards automatic WCE image analysis.

A study comparing an endoscopy nurse and an endoscopy physician in capsule endoscopy interpretation.

OBJECTIVE: Complete review of wireless capsule endoscopy (WCE) recordings by a physician is time-consuming and laborious and may be perceived as a limitation to perform WCE. The aim of this study was to evaluate the efficacy of a nurse in interpreting WCE. METHODS: A total of 102 WCE videos were evaluated by a single gastroenterologist and a nurse experienced as an assistant in diagnostic and interventional endoscopy and trained in WCE. After independently reviewing WCE videos, the two readers discussed their findings and came to a consensus. RESULTS: The mean capsule reading time was significantly longer for the nurse compared with the gastroenterologist (117.3+/-24.8 vs. 63.8+/-8.5 min, P<0.001). No statistical differences were observed regarding the correct recognition of first gastric, duodenal and caecal images between the two readers. For the gastroenterologist, both sensitivity and specificity in detecting abnormal findings were 100% except for angiodysplasia [sensitivity 88.5%, 95% confidence interval (CI): 70-97.4]. For the nurse, the lowest sensitivity rates were in detecting polyps (70%, 95% CI: 34.9-92.3) and angiodysplasias (92.3%, 95% CI: 74.8-98.9). The interobserver agreement as determined by Cohen's κ coefficient was excellent except for polyps (k=0.71, 95% CI: 0.46-0.96). CONCLUSION: A trained nurse is highly accurate in detecting abnormal findings and interpreting WCE recordings. Physician's role could be limited to consider and confirm thumbnails created by a nurse.

Abnormal pattern detection in Wireless Capsule Endoscopy images using nonlinear analysis in RGB color space.

In recent years, an innovative method has been developed for the non-invasive observation of the gastrointestinal tract (GT), namely Wireless Capsule Endoscopy (WCE). WCE especially enables a detailed inspection of the entire small bowel and identification of its clinical lesions. However, the foremost disadvantage of this technological breakthrough is the time consuming task of reviewing the vast amount of images produced. To address this, a novel technique for distinguishing pathogenic endoscopic images related to ulcer, the most common disease of GT, is presented here. Towards this direction, the Bidimensional Ensemble Empirical Mode Decomposition was applied to RGB color images of the small bowel acquired by a WCE system in order to extract their Intrinsic Mode Functions (IMFs). The IMFs reveal differences in structure from their finest to their coarsest scale, providing a new analysis domain. Additionally, lacunarity analysis was employed as a method to quantify and extract the texture patterns of the ulcer regions and the normal mucosa, respectively, in order to discriminate the abnormal from the normal images. Experimental results demonstrated promising classification accuracy (>95%), exhibiting a high potential towards WCE-based analysis.

Comparison of two schemes of small bowel preparation for capsule endoscopy with polyethylene glycol: a prospective, randomized single-blind study.

OBJECTIVE: Small bowel preparation for capsule endoscopy remains controversial. This study was conducted to compare the efficacy of 2 and 4 l of polyethylene glycol. METHODS: One hundred and one patients (group A) received 2 l and 100 (group B) received 4 l in a prospective, randomized single-blind trial. To objectively evaluate enteric preparation, a cleansing coefficient was calculated for each patient. RESULTS: The two groups were found comparable regarding age, sex, body mass index, and reason for referral. In 82 patients of group A and in 76 of group B, examination of small bowel was completed (P =0.40). Gastric emptying time and small bowel transit time were found comparable in both groups. Cleansing coefficients, for small bowel as a whole or for proximal or distal separately, were similar among the two groups. However, the cleansing coefficient of the proximal bowel was significantly higher than that of the distal, independently of preparation (group A: P < 0.001, group B: P< 0.001). Small bowel preparation was related only with the age of the patients and gastric emptying time; the younger the patient or the shorter the gastric emptying time, the higher the cleansing coefficient. Pathological findings were found in 43 (42.6%) patients of group A and in 37 (37.0%) patients of group B (P =0.42). A final positive diagnosis was established in 33 (32.7%) patients of group A and in 29 (29.0%) of group B (P = 0.57). CONCLUSION: The two schemes were equal regarding enteric cleansing and completion of the procedure. Therefore, 2 l seems to be an adequate preparation for capsule endoscopy.

Capsule retention: a feared complication of wireless capsule endoscopy.

Wireless capsule endoscopy is a simple, non-invasive technique for the visualization of the entire small bowel. It was introduced in clinical praxis in 2001 and has already become the method of choice for the investigation of small-bowel pathology. Capsule retention is a major complication, with an overall incidence of 1-2%, although reported rates vary widely from 0% to 21%, depending on the indication for the examination. This complication can occur at any level of the gastrointestinal tract and in most cases runs asymptomatically. However, symptomatic bowel obstruction requiring surgical or endoscopic removal of the impacted capsule can occur. Rarely, capsule retention can lead to intestinal perforation. Despite several years of experience with wireless capsule endoscopy, there is up to the present no safe means of predicting capsule retention. Radiological studies have a low diagnostic yield and tend to underestimate or overestimate small-bowel strictures. The role of the new generation patency capsule (Agile patency capsule) needs to be further documented. The experts agree that obtaining a careful history is perhaps the best single method to detect the possibility of retention.

Acute pancreatitis associated with herpes simplex virus infection: report of a case and review of the literature.

Although a wide variety of infectious agents have been implicated in the aetiology of acute pancreatitis, their true incidence is unknown because they coexist quite often with other noninfectious causes. Acute herpes simplex viral pancreatitis is a rarely encountered entity in the literature. We report a patient who developed acute pancreatitis and hepatitis in association with herpes simplex virus infection as well as cholestatic syndrome because of compression of the intrapancreatic part of the common bile duct by the oedematous pancreatic head. Herpes simplex virus infection, although a rare entity, should be included in the conditions causing acute pancreatitis, when common noninfectious factors have been excluded and hepatic inflammation coexists. Diagnostically, a combination of serum amylase or lipase elevation, more than three times over the upper normal limits, as well as serologic evidence of the infectious agent should exist. Dilatation of the biliary tree is not invariably compatible with a biliary cause of acute pancreatitis.

Capsule endoscopy in the investigation of patients with portal hypertension and anemia.

INTRODUCTION: Data on small bowel abnormalities in patients with portal hypertension (PHT) are limited. Bleeding from the gastrointestinal tract and anemia are common complications in these patients. Capsule endoscopy (CE) was used to evaluate small bowel (SB) pathology in patients with PHT and anemia, and possible associations with various parameters were examined. METHODS: Thirty-five patients with PHT referred for CE investigation of the SB for anemia were prospectively enrolled in the study, as well as 70 age- and sex-matched control patients with anemia, normal liver function and no evidence of PHT who underwent CE. RESULTS: Findings compatible with portal hypertensive enteropathy (PHE) were detected in 65.7% of the patients and in 15.7% of the controls chi2=26.641, P=0.000). Abnormalities in PHT patients included varices in 25.7%, diffuse changes of mucosa with inflammatory-like appearance in 42.9%, and angiodysplasias and/or spider angiomas in 22.9% of cases. The presence of PHE was significantly associated only with the presence of severe portal hypertensive gastropathy, while the presence of SB varices alone was significantly associated with the presence of severe portal hypertensive gastropathy, larger esophageal varices and the presence of colonic varices. CONCLUSIONS: Varices, diffuse changes of mucosa with inflammatory-like appearance, and angiodysplasias and/or spider angiomas are detected more often in patients with PHT than in controls, and probably constitute the endoscopic characteristics of PHE. CE of the SB added a significant number of likely important findings to those detected by conventional endoscopic techniques for the clinical management of patients with PHT and anemia.