Risk factors for local recurrence of large gastrointestinal lesions after endoscopic mucosal resection.

BACKGROUND: Endoscopic mucosal resection (EMR) is the primary treatment modality for superficial gastrointestinal mucosal lesions > 2 cm. However, the procedure carries some risk of complications including bleeding, perforation, and local recurrence. This study aimed to examine factors associated with EMR outcomes, especially in terms of local recurrence. METHODS: This study retrospectively evaluated patients who underwent EMR and full closure with prophylactic clips for upper and lower gastrointestinal lesions > 2 cm at Cleveland Clinic Florida, between January 2013 and December 2018 with follow-up endoscopic evaluation for recurrence. RESULTS: A total of 2031 endoscopic polypectomy cases were examined; 307 EMR procedures among 271 patients (52% were female, mean age 65.6 ± 11.1 years) who satisfied the inclusion criteria were included in the study. There were no perforations reported. The rate of post-polypectomy delayed bleeding was 1.6%, and the local recurrence rate in this cohort was 7.1%. Recurrent cases were successfully endoscopically managed. In the multivariate regression analysis, age > 70 years (OR = 3.20, 95% CI 1.17-8.76, p = .023), body mass index (OR = 1.12, 95% CI 1.03-1.23 p = .008), and lesion size ≥ 35 mm (OR = 11.51, 95% CI 3.54-37.40, p = < .001) were independent predictors for recurrence. CONCLUSIONS: Age > 70 years, increased lesion size, and obesity were found to be independent predictors of local recurrence among EMR procedures for gastrointestinal lesions > 2 cm. However, there is a need for larger-scale studies on this topic.

Risk Factors Associated With Postendoscopic Mucosal Resection Bleeding in Patients With Cirrhosis: A Retrospective Multicenter Cohort Study.

BACKGROUND AND AIM: There is limited data regarding the safety of endoscopic mucosal resection (EMR) in the cirrhotic population. Our study aimed to evaluate the safety of colonoscopic EMR in cirrhosis. MATERIALS AND METHODS: This was a retrospective review of cirrhotics who underwent colonic EMR at 8 Cleveland Clinic Centers between January 1, 2006, and December 31, 2018. Patient data including polyp details and complications occurring within 30 days of the procedure were noted. Univariable and multivariable logistic regression analyses were conducted to find risk factors for post-EMR bleeding. RESULTS: A total of 238 patients who underwent EMR were included. There were 145 males (60.9%) and the mean age was 61.9±8.6 years. Immediate and delayed bleeding, and postpolypectomy syndrome rates were 9.2%, 5.8%, and 1.3%, respectively. Significant risk factors for postpolypectomy bleeding were: increased age (P=0.001), procedure duration >37 minutes (P=0.001), antiplatelet use within 5 days (P=0.023), and lesion diameter >15 mm (P=0.004). Multivariable analysis revealed independent predictors of procedure-related bleeding: age above 65 years [odds ratio (OR) 2.14, P=0.044], antiplatelet use within 5 days (OR 2.42, P=0.047), right colon polyp (OR 3.51, P=0.001), and lesion diameter >15 mm (OR 3.22, P=0.003). CONCLUSIONS: EMR in cirrhotics has an acceptable bleeding risk. Age above 65 years, right colon polyp, polyp size >15 mm, and use of antiplatelets within 5 days are independent risk factors for bleeding.

Left atrial deformation parameters in patients with non-alcoholic fatty liver disease: a 2D speckle tracking imaging study.

The presence of the metabolic syndrome is a strong predictor for the presence of NASH (non-alcoholic steatohepatitis) in patients with NAFLD (non-alcoholic fatty liver disease). In the present study, we assessed LA (left atrial) deformation parameters in patients with NAFLD using 2D-STE (speckle tracking echocardiography) and to investigate if any changes exist between subgroups of the NAFLD. A total of 55 NAFLD patients and 21 healthy controls were included in the study. The diagnosis of NAFLD was based on liver biopsy. After patients were categorized into groups according to histopathological analysis (simple steatosis, borderline NASH, definitive NASH), all patients underwent echocardiography with Doppler examination. In the 2D-STE analysis of the left atrium, LA-Res (peak LA strain during ventricular systole), LA-Pump (peak LA strain during atrial systole), LA-SR(S) (peak LA strain rate during ventricular systole), LA-SR(E) (peak LA strain rate during early diastole) and LA-SR(A) (peak LA strain rate during atrial systole) were obtained. LA-Res, LA-Pump and LA-SR(A) were lower in the NAFLD group than in the control group. LA-Res was found to be significantly lower in NAFLD subgroups compared with healthy subjects (43.9±14.2 in healthy controls compared with 31.4±8.3 with simple steatosis, 32.8±12.8 with borderline NASH and 33.8±9.0 with definitive NASH). LA-Pump was significantly lower in the NAFLD group (18.2±3.1 in healthy controls compared with 13.3±4.7 with borderline NASH and 14.4±4.7 with definitive NASH). There were significant differences in LA-SR(A) between healthy controls compared with simple steatosis and borderline NASH (-1.56±0.36 compared with 1.14±0.38 and 1.24±0.32 respectively). Correlation analysis showed significant correlation of LA-Res values with E (early diastolic peak velocity)/E(m) (early diastolic mitral annular velocity) ratio (r=-0.50, P≤0.001), with LAVI (LA volume index; r=-0.45, P≤0.001) and with V(p) (propagation velocity; r=0.39, P≤0.001). 2D-STE-based LA deformation parameters are impaired in patients with NAFLD with normal systolic function. Although LA-Res and pump function parameters might be useful in estimating LV (left ventricular) filling pressure in the NAFLD patient group, it could not be used for differentiating the subgroups.

HLA DQB1 alleles are related with nonalcoholic fatty liver disease.

Nonalcoholic fatty liver disease (NAFLD) is the leading cause of chronic liver disease. NAFLD is a complex disease and inflammation is a crucial component in the disease pathogenesis. Recent genome wide association studies in hepatology area highlighted significant relations with human leukocyte antigen (HLA) DQ region and certain liver diseases. The previous animal models also emphasized the involvement of adaptive immune system in the liver damage pathways. To investigate possible polymorphisms in the HLA region that can contribute to the immune response affecting the NAFLD, we enrolled 93 consecutive biopsy proven NAFLD patients and a control group consisted of 101 healthy people and genotyped HLA DQB1 alleles at high resolution by sequence specific primers-polymerase chain reaction. The mean NAFLD activity score (NAS) was 5.2 ± 1.2, fibrosis score was 0.9 ± 0.9, ALT was 77 ± 47.4 U/L, AST was 49.4 ± 26.3 U/L. Among 13 HLA DQB1 alleles analyzed in this study, DQB1*06:04 was observed significantly at a more frequent rate among the NAFLD patients compared to that of healthy controls (12.9 vs. 2 % χ(2) = 8.6, P = 0.003, P c = 0.039, OR: 7.3 95 % CI 1.6-33.7). In addition, the frequency of DQB1*03:02 was significantly higher in the healthy control group than the NAFLD patients (24.8 vs. 7.5 %, χ(2) = 10.4, P = 0.001, P c = 0.013, OR: 0.2, 95 % CI 0.1-0.6). NAFLD patients were grouped according to their fibrosis score and NAS. The distribution of DQB1 alleles over stratified NAFLD patients did not reveal any statistically significant relation. Taken together, immune repertoire of individuals may have an effect on NAFLD pathogenesis and therefore, in NAFLD, adaptive immunity pathways should be investigated.

Characterization of nonalcoholic fatty liver disease unrelated to the metabolic syndrome.

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) is the hepatic manifestation of the metabolic syndrome (MS). However, not all patients with the MS will develop NAFLD and not all patients with NAFLD have the MS. We sought to investigate the differences between patients with biopsy-proven NAFLD with and without the MS. METHODS: A total of 357 consecutive patients with biopsy-proven NAFLD were analysed. Of them, 216 patients had nonalcoholic steatohepatitis (NASH) and 96 a fibrosis score ≥ 2. The MS was defined as ≥ 3 of the ATP III criteria. RESULTS: A total of 214 patients with NAFLD met the criteria for the MS, while the remaining 143 did not. In NAFLD patients with the MS, homeostasis model of insulin resistance (P = 0·03; OR, 1·06; 95% CI, 1·023-1·25 per unit increase) and diabetes (P = 0·01; OR, 1·2; 95% CI, 1·1-2·4) were independent predictors of NASH. In NAFLD patients without the MS, the only variable independently associated with NASH was haemoglobin (P = 0·007; OR, 1·9; 95% CI, 1·4-3·6 per 50 g/L increase). Alanine aminotransferase (P = 0·03; OR, 1·04; 95% CI, 1·006-1·11 per 10 U/L increase) was an independent predictor of fibrosis ≥ 2 in NAFLD patients with the MS, while haemoglobin (P = 0·02; OR, 1·4; 95% CI, 1·2-1·9 per 50 g/L increase) was the only variable significantly associated with fibrosis ≥ 2 in NAFLD patients without the MS. CONCLUSIONS: Increased haemoglobin in NAFLD subjects without MS should be considered in the selection of cases for histological assessment.

Hepatic expression and serum levels of syndecan 1 (CD138) in patients with nonalcoholic fatty liver disease.

BACKGROUND AND AIMS: Syndecan-1 (CD138) is a transmembrane heparan sulfate proteoglycan expressed in the liver which may exert metabolic effects by mediating the hepatic clearance of triglyceride-rich lipoproteins. In the present study, we assayed serum levels and the hepatic expression of syndecan-1 and examined their association with clinical, biochemical, and histologic phenotypes in patients with histology-proven nonalcoholic fatty liver disease (NAFLD). METHODS: A total of 59 patients with biopsy-proven NAFLD and 54 matched controls were enrolled. The analysis of syndecan-1 expression in liver biopsies was performed by immunohistochemistry on formalin-fixed, paraffin-embedded samples. Serum syndecan-1 levels were measured by ELISA. RESULTS: NAFLD patients had significantly higher serum syndecan-1 levels [median: 61 ng/mL (interquartile range: 36-97 ng/mL)] than controls [median: 37 ng/mL (interquartile range: 25-59 ng/mL, Mann-Whitney U test, p < 0.001]. However, we did not find any significant association between serum syndecan-1 and the mean syndecan-1 immunohistochemical score (n = 59, r = 0.064, p = 0.63). Interestingly, the syndecan-1 immunohistochemical score was an independent predictor of HDL cholesterol in NAFLD patients (ß = 0.27; t = 1.99, p < 0.05). CONCLUSIONS: Our data suggest that serum syndecan-1 levels are raised in patients with NAFLD. Moreover, the syndecan-1 immunohistochemical score in the liver is independently associated with HDL cholesterol in this group of patients. These pilot results support further investigation of this molecule in metabolic liver diseases.

Potential clinical complications of Orise™ gel use, a new submucosal lifting agent: experience from a tertiary care center and review of the literature.

Background: Endoscopic mucosal resection (EMR) involves forming a fluid cushion in the submucosal area with a lifting agent, followed by superficial resection. Orise™ gel is one of the commonly used lifting agents for EMR. We present a case series and literature review that analyzes the characteristic histopathological findings and clinical implications observed where Orise™ gel was used before EMR. Methods: Colon resection specimens and prior EMR specimens where Orise™ gel was used were reviewed for patients undergoing EMR between January 2018 and December 2020. The literature review included relevant studies from the Medline and Cochrane databases from January 2018 to December 2020. Results: A total of 12 colon polyp EMRs using Orise gel were performed during the study period. Seven patients (58.34%) underwent surgical resection. Histological examination revealed that, after the EMR procedure, the Orise™ gel material changed its morphological characteristics over time from a basophilic (bluish) non-inflamed pattern to an eosinophilic (pink) type pattern, eliciting a foreign body reaction. The endoscopic appearance and examination of the excised specimens weeks after injection gave the impression of a mass in some cases. The material was also present transmurally and in some cases in the peri-intestinal adipose tissue. Conclusions: It was observed that Orise™ gel use elicits a foreign body-type granulomatous reaction. This potential side effect may lead to overdiagnosis of a mass/lesion and unnecessary surgical interventions. This case series and review of the literature aims to increase awareness of the changes caused by Orise™ gel in the gastrointestinal tract.

SIRT1 as a potential therapeutic target for treatment of nonalcoholic fatty liver disease.

Sirtuins are members of the silent information regulator 2 (Sir2) family, a group of Class III histone/protein deacetylases. There are 7 different sirtuins in mammals (SIRT1-7), of which SIRT1 is the best known and most studied. SIRT1 is responsible for the regulation of protein activation by means of deacetylating a variety of proteins that play important roles in the pathophysiology of metabolic diseases. Recently, it has been shown that SIRT1 plays key roles in the regulation of lipid and glucose homeostasis, control of insulin secretion and sensitivity, antiinflammatory effects, control of oxidative stress and the improvements in endothelial function that result due to increased mitochondrial biogenesis and ß-oxidation capacity. Nonalcoholic fatty liver disease (NAFLD) is currently the most common liver disease, and it has been accepted as the hepatic component of metabolic syndrome. Recent studies have shown that SIRT expression in the liver is significantly decreased in an NAFLD model of rats fed a high-fat diet, and moderate SIRT1 overexpression protects mice from developing NAFLD. In addition to resveratrol, a natural SIRT1 activator, small-molecule pharmacologic SIRT1 activators have positive effects on metabolic diseases. These effects are particularly promising in the case of diabetes mellitus, for which phase studies are currently being performed. With this information, we hypothesized that the pharmacologic activation of SIRT1, which has been implicated in the pathogenesis of NAFLD, will be a potential therapeutic target for treating NAFLD. In this paper, we review the metabolic effects of SIRT1 and its association with the pathophysiology of NAFLD.

Plasma fibrinogen-like protein 2 levels in patients with non-alcoholic fatty liver disease.

BACKGROUND/AIMS: Fibrinogen-like protein 2 (fgl2), has recently been identified as a new member of the fibrinogen-like family of proteins. In this study we assayed plasma levels of fgl2 in patients with biopsy proven non-alcoholic fatty liver disease (NAFLD) and examined their association with clinical, biochemical and histological phenotypes. METHODOLOGY: Levels of plasma fgl2 were measured by enzyme linked immunosorbent assay and compared between the study groups. Moreover, concentrations of fgl2 were assessed in relation to the general characteristics of the study participants and the results of the liver biopsy. RESULTS: Levels of fgl2 were significantly higher in patients with definite non-alcoholic steatohepatitis (NASH) (788±190pg/mL, p<0.001) and borderline NASH (710 ± 140pg/mL, p<0.001) compared with controls (515±174pg/mL). No significant differences were found in patients with simple steatosis (649 ± 162pg/mL) as compared with controls. There were no associations between the plasma fgl2 levels with the fibrosis stage and steatosis grade. CONCLUSIONS: Although subject to future confirmation, our data suggest that fgl2 levels are elevated in the more severe forms of NAFLD.

An Alternative Method for Treating Dumping Syndrome Using Hemoclips.

Surgeries for obesity can lead to complications. Dumping syndrome is one such complication caused by the quick passage of hyperosmolar chyme from the stomach to the duodenum. Mild cases can be cured with dietary modification and medical treatment. However, refractory cases may need invasive treatment options, such as transoral outlet reduction or surgery. We successfully treated a 48-year-old female with dumping syndrome, using a combination of argon plasma coagulation and hemoclips to narrow the pyloric lumen. We suggest that this new technique could be a cheap and easily accessible alternative to surgery, especially in countries where the specialised devices needed to treat such cases are unavailable.

Pathogenetic mechanisms of nonalcoholic fatty liver disease and inhibition of the inflammasome as a new therapeutic target.

Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease worldwide, and its incidence is increasing. Nonalcoholic steatohepatitis (NASH), the progressive form of the disease, can lead to end-stage liver disease. The pathogenesis of the disease is not fully understood, and there is currently no specific treatment. Therefore, an effective and reliable treatment modality is needed. In recent years, the inflammasome has been shown to play a vital role in many stages of NAFLD pathogenesis. In particular, the detection, by toll-like receptors, of pathogen-associated molecular patterns induced by the gut-liver axis triggers the formation of the NLRP3 (NLR family pyrin domain-containing protein 3) inflammasome. Stimulation of damage-associated molecular patterns also activates the NLRP3 inflammasome. The activated inflammasome has caspase-1 activity, which leads to the release of interleukin (IL)-1 and IL-18 and formation of pores in the cell wall. This process spreads the inflammatory process to the outside of the cell and induces inflammatory cell death (pyroptosis). Subsequent progression of the inflammatory process leads to fibrosis. Recent evidence suggests that the NLRP3 inflammasome may be a potential target for the treatment of NASH. The discovery of specific NLRP3 inflammasome blockers in recent years and evidence of their positive effects in experimental models support this therapeutic approach. In this article, we discuss recent evidence on the pathogenesis of NAFLD, the role of the inflammasome in the pathogenesis of NAFLD, and the potential effects of inhibition of the inflammasome.

Visceral Adiposity Index As a Practical Tool in Patients with Biopsy-Proven Nonalcoholic Fatty Liver Disease/Nonalcoholic Steatohepatitis.

Aim: Our study aimed to examine the relationship of the visceral adiposity index (VAI) with clinical and histological parameters in biopsy-proven nonalcoholic fatty liver disease (NAFLD) cases and evaluate its place in clinical practice. Materials and Methods: The study included 57 biopsy-proven NAFLD cases and 57 healthy controls. The VAI values of the cases were calculated with the formula based on body mass index, waist circumference, triglycerides, and high-density lipoprotein cholesterol levels. The relationships between VAI values and clinical and histological parameters were examined. Results: While the VAI was significantly higher in the NAFLD cases in comparison to the control group (3.5 ± 3.09 vs. 1.60 ± 0.98, respectively, P < 0.001), this difference was more noticeable in the nonalcoholic steatohepatitis (NASH) group (3.60 ± 3.35) (P < 0.001). In distinguishing the NAFLD group and the healthy group in VAI, it was determined that VAI had a sensitivity of 72%, specificity of 68%, and an area under the receiver operating characteristic curve value of 76.9%. No significant relationship was found between the histological parameters and VAI scores. Conclusions: Our study showed that VAI was increased in the NAFLD cases. This increase was observed to be more noticeable in especially the NASH cases. It is possible for this index to be a practical modality that could be used in clinical practice in prediction of especially NASH cases, which constitute the progressive form of the disease, but in this sense, there is a need for further studies.

Early Detection of Hepatocellular Carcinoma Recurrence in the Posttransplant Population: A Comparison of RETREAT and Cleveland Clinic Florida Scoring System.

BACKGROUND: Liver transplantation (LT) for hepatocellular carcinoma (HCC) is curative in most cases; however, recurrence is observed in some patients. The Risk Estimation of Tumor Recurrence After Transplant (RETREAT) score is an externally validated scoring system for prediction of post-LT HCC recurrence. The Cleveland Clinic Florida Scoring System (CCFSS) is a potential new scoring system for prediction of HCC recurrence. Our study aimed to compare the RETREAT and CCFSS. METHODS: We conducted a retrospective cohort study of 52 adult patients with HCC who underwent LT at a tertiary care center. Mantel-Haenszel chi-square analyses were conducted to compare the RETREAT and CCFSS classifications for detecting HCC recurrence. RESULTS: A total of 52 patients underwent LT. The median follow-up period was 37 months. Four patients had post-LT HCC recurrence, with all recurrences occurring within 2 years of LT. The RETREAT score was better able to detect low, moderate, and high levels of risk (P < .001), compared to the CCFSS score (P = 0.480). Both risk scores had a sensitivity of 75%; the specificity of the RETREAT score was 95.8%, whereas the specificity of the CCFSS was 60.4%. Alpha-fetoprotein level at the time of LT was associated with HCC recurrence (P = .014). CONCLUSIONS: This is the first study to evaluate the CCFSS as a potential new scoring system to predict HCC recurrence after LT. The RETREAT score is more specific than the CCFSS. The incorporation of alpha-fetoprotein level at the time of LT improves the estimation of HCC recurrence in the post-LT period.

Metastatic gastric melanoma: a challenging diagnosis.

BACKGROUND: The stomach is regarded as a rare site for metastasis. When a gastric mass is observed macroscopically, the presumed diagnosis is usually a primary gastric carcinoma. However, the stomach may be involved in metastatic malignant melanoma. Besides a possible macroscopical misdiagnosis, metastatic gastric melanoma may also be misdiagnosed microscopically as adenocarcinoma due to its protean histological characteristics. These features make metastatic gastric melanoma a challenging diagnosis in some cases. CASE REPORT: We report a patient with metastatic gastric melanoma referred to us with an initial macroscopic and histopathological diagnosis of primary gastric adenocarcinoma. He was diagnosed as having metastatic gastric melanoma by further examination because of the peculiar metastatic involvement and normal gastrointestinal tumor marker levels. CONCLUSIONS: The stomach may be involved in melanoma and melanoma metastasis to the stomach is a diagnosis that should be taken into account while evaluating any gastric mass lesion. It is likely to be encountered more commonly nowadays due to the significant increase in the melanoma incidence. A history of melanoma, an atypical metastatic pattern, and normal gastrointestinal tumor marker levels may contribute to its diagnosis.

Recurrent Gastrointestinal Bleeding in an HIV-Positive Patient: A Case Report.

HIV is a global epidemic that needs a multidisciplinary approach. Gastrointestinal bleeding is uncommon in HIV-positive patients. In cases such as bacillary angiomatosis, Kaposi sarcoma, herpes simplex, histoplasmosis, and cytomegalovirus (CMV) colitis, the underlying reason could be HIV. The reason could also be unrelated to HIV, such as peptic ulceration, esophageal varices, and Mallory-Weiss. In our case, we report a patient who was admitted to the hospital three times. In the first admittance, he indicated using multiple nonsteroidal anti-inflammatory drugs (NSAIDs); however, we could not find the bleeding focus. He underwent surgery, at which time we detected a Kaposi sarcoma.

Utility and safety of balloon-assisted enteroscopy in patients with left ventricular assist devices: a retrospective multicenter study.

Objective and study aims Patients with left-ventricular assist devices (LVADs) have an increased risk of gastrointestinal bleeding, especially from the small bowel, often necessitating evaluation with balloon-assisted enteroscopy (BAE). Our study aimed to assess the periprocedural safety and utility of BAE for gastrointestinal bleeding in patients with LVADs. Patients and methods This was a multicenter retrospective cohort study of adults with LVADs who underwent BAE between January 2007 to December 2018. Results Thirty-four patients underwent a total of 46 BAEs (9 were single-balloon enteroscopies [SBEs] and 37 were double-balloon enteroscopies [DBEs]). Mean age of patients was 66.4 ±â€Š8.3 years. Patients tolerated anesthesia well, without complications. There were no complications from the BAE itself. One patient required repeat BAE due to a progressive drop in hemoglobin and another patient developed paroxysmal supraventricular tachycardia. One patient died within 72 hours of the procedure due to worsening of LVAD thrombosis. Diagnostic yields were 69.6 % for all procedures, 73.0 % for DBE and 55.6 % for SBE ( P  = 0.309). Therapeutic yields were 67.4 % overall: 73.0 % for DBE and 44.4 % for SBE ( P  = 0.102). In those that presented with overt gastrointestinal bleeding, DBE had a higher diagnostic yield compared to SBE (84.2 % vs. 42.9 %; P  = 0.057) and a significantly higher therapeutic yield (84.2 % vs. 28.6 %; p = 0.014). Conclusions This is the largest multicenter study of patients with LVADs who underwent DBE. BAE appears to be a safe and useful modality for the evaluation of gastrointestinal bleeding in these patients.

Therapeutic success with bismuth-containing sequential and quadruple regimens in Helicobacter pylori eradication.

BACKGROUND AND STUDY AIMS: The success rate of Helicobacter pylori (H. pylori) eradication with the classical triple therapy is gradually declining. In this study, we aimed to compare and assess the efficacies of six different eradication regimens including sequential protocols. PATIENTS AND METHODS: Endoscopically confirmed nonulcer dyspepsia patients were enrolled. H. pylori presence was determined either histologically or by a rapid urease test. Treatment-naive patients were randomly assigned to an either one of three 10-day (OAC, OTMB, and OACB) or one of three sequential protocols (OA+OCM, OA+OCMB, and OA+OMDB) (O=omeprazole, A=amoxicillin, C=clarithromycin, T=tetracycline, M=metronidazole, B=bismuth, D=doxycycline). The eradication was assessed 6-8weeks after the completion of the treatment by a 14C-urea breath test. RESULTS: In total, 301 patients were included. Fifty-two percent of the participants (n=157) were female, and the mean age was 44.9years (range=18-70). The intention to treat (ITT) and per protocol (PP) eradication rate for each regimen is as follows: OAC (ITT=61.2%, PP=75%), OTMB (83.3%, 87%), OACB (76.5%, 79.6%), OA+OCM (72.3%, 73.9%), OA+OCMB (82.7%, 89.6%), and OA+OMDB (59.3%, 65.3%). Smoking significantly affected the eradication rate (P=0.04). CONCLUSION: In this study, OTMB and OA+OCMB were significantly superior to the triple therapy and succeeded to reach the eradication rate proposed by the Maastricht consensus (over 80%). These two bismuth-containing regimens could be considered for first-line therapy in the regions with high clarithromycin resistance.