Endoscopic submucosal dissection versus endoscopic mucosal resection for type 0-II superficial gastric lesions larger than 20 mm.

BACKGROUND: Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are increasingly used for the treatment of superficial gastrointestinal neoplasia. However, the limits and the indications for each technique are still debated. Our retrospective study aimed to compare these techniques in patients with gastric flat lesions larger than 20 mm without the non-lifting sign. METHODS: Between January 2013 and July 2016, a total of 36 patients with early gastric flat lesions larger than 20 mm and without the non-lifting sign were resected by ESD and were followed up by endoscopy. As a control group, 40 EMR cases from our database were matched. En bloc and curative resection were compared between the two groups according to histological assessment, tumor size, recurrence, complication rate, and procedure time. A Kaplan-Meier comparison was performed for both groups with a log-rank test to compare the survival curves; the chi-square test was employed for other parameters. RESULTS: En bloc resection rate and curative resection rate were significantly higher in the ESD group than in the EMR group. Procedure time was significantly longer in the ESD group. No significant differences were found in the recurrence and complication rates, although the former were higher in the EMR group and the latter in the ESD group. Survival curves were similar for both groups. CONCLUSIONS: Our retrospective analysis seems to confirm a clear advantage for ESD over EMR in removing early superficial gastric neoplasm. Although ESD has expanded the endoscopic resectability of endoscopic gastric lesions, EMR may still be considered one of the therapeutic options for flat gastric lesions without the non-lifting sign.

Primary clarithromycin resistance in Helicobacter pylori: the Multicentric Italian Clarithromycin Resistance Observational (MICRO) study.

BACKGROUND: Primary clarithromycin resistance markedly reduces Helicobacter pylori eradication rate following standard therapies. Prevalence of primary clarithromycin resistance in H. pylori is increasing, and three point mutations are mainly involved. AIM. To assess both the prevalence of primary clarithromycin resistance in Italy, and the distribution of the involved point mutations. METHODS: Primary clarithromycin resistance was assessed by TaqMan real-time polymerase chain reaction on antral biopsies of 253 consecutive, H. pylori infected patients enrolled in 13 Italian centres between January and September 2010. RESULTS: Primary clarithromycin resistance was detected in 25 (9.9%) patients, with prevalence values widely ranging from 0 to 25%. Clarithromycin resistance rate was higher in female as compared to male patients (13.4% vs. 5.3%, p=0.03), and it tended to be higher in non-ulcer dyspepsia than in peptic ulcer patients (10.6% vs. 6.9%, p=0.5), female patients with non-ulcer dyspepsia showing the highest value (15.4%). The A2143G point mutation was detected in 13 (52.0%) patients, the A2142G in 9 (34.6%), whilst a double point mutation (A2143G plus A2142G) in 3 (11.6%) cases. CONCLUSIONS: Primary clarithromycin resistance is highly variable in different Italian geographic areas. High resistance rates were observed in female and in dyspeptic patients. Among the three point mutations of clarithromycin resistance, the A2143G remains the most frequently observed.

Outcome of nonerosive gastro-esophageal reflux disease patients with pathological acid exposure.

AIM: To assess the management and outcome of nonerosive gastro-esophageal reflux disease (NERD) patients who were identified retrospectively, after a 5-year follow-up. METHODS: We included patients with gastro-esophageal reflux disease (GERD) symptoms who had a negative endoscopy result and pathological 24-h esophageal pH-monitoring while off therapy. We interviewed them after an average period of 5 years (range 3.5-7 years) by means of a structured questionnaire to assess presence of GERD symptoms, related therapy, updated endoscopic data and other features. We assessed predictors of esophagitis development by means of univariate and multivariate statistical analysis. RESULTS: 260 patients (137 women) were included. Predominant GERD symptoms were heartburn and regurgitation in 103/260 (40%). 70% received a maintenance treatment, which was proton pump inhibitor (PPI) in 55% of cases. An average number of 1.5 symptomatic relapses per patient/year of follow-up were observed. A progression to erosive gastro-esophageal reflux disease (ERD) was found in 58/193 (30.0%) of patients undergoing repeat endoscopy; 72% of these were Los Angeles grade A-B. CONCLUSION: This study shows that progression to ERD occurs in about 5% of NERD cases per year, despite therapy. Only two factors consistently and independently influence progression: smoking and absence of PPI therapy.

[Magnetic oesophageal sphincter for the treatment of gastro-oesophageal reflux disease: results of a prospective clinical trial]. / Sfintere esofageo magnetico nel trattamento della malattia da reflusso gastroesofageo: risultati di uno studio prospettico.

The authors report the preliminary results of a prospective study in 30 patients with gastro-oesophageal reflux disease. The aim was to assess the efficacy of an-original device designed to augment the lower oesophageal sphincter barrier using magnetic force. The device was placed laparoscopically around the oesophagogastric junction, at the level of the z line identified by intraoperative endoscopy. Transient dysphagia not requiring any treatment was recorded in 45% of patients. At 3 months postoperatively, the GORD-HRQL score was fond to be significantly decreased from 24.4 to 2.2 (p < 0.001) and the DeMeester score was normalised in 80% of patients. At one year follow-up, 100% of patients were off proton pump inhibitors, and 70% of them had a normal DeMeester score. All patients preserved the ability to belch.

Use of double-balloon enteroscopy in the management of patients with Crohn's disease: feasibility and diagnostic yield in a high-volume centre for inflammatory bowel disease.

BACKGROUND: Double-balloon enteroscopy (DBE) is theoretically useful in Crohn's disease (CD) since it is potentially able to investigate the whole small intestine, but sparse data are available. AIM: To assess the feasibility, safety, and diagnostic yield of DBE in CD. METHODS: The study was conducted in a tertiary care centre for inflammatory bowel disease. Thirty-seven patients with CD (18/19 male/female, mean age 42 years, range 13-77 years) were considered. Thirty-two DBEs from the oral approach and 18 from the anal (in 6 patients from both ways with a complete exploration in 4, 10.8%) were performed. Indications were: first diagnosis/staging in 16 cases, diagnosis of stenosis in 7, obscure bleeding in 10, suspected neoplasia in 2, and postsurgical evaluation in 2. One hundred and thirty-three other procedures (3.7 per patient) were performed with the same indication. RESULTS: Insertion depth from the oral route was 266.5 ± 100 cm and from the anal route 72.5 ± 60 cm. Ileocecal valve was passed in 8/13 patients, but in 4 DBE explored less than 50 cm of ileum. Diagnostic yield was 59.4% but changed according to indication (40% in obscure bleeding, 100% in case of strictures) and was higher when DBE was conducted on the basis of previous investigations (77.8% versus 40%, p = 0.037). CONCLUSION: DBE is a feasible, useful, but technically demanding method in CD. Definition of the proper introduction route by means of previous investigations is associated with a higher efficacy of DBE.

Rabeprazole: a second-generation proton pump inhibitor in the treatment of acid-related disease.

Rabeprazole is a proton pump inhibitor (PPI) presenting a very advantageous pharmacodynamic and pharmacokinetic profile over older PPIs. In particular, this drug has a very fast onset of action, due to a short activation time and a very high pKa, and may therefore be defined as a 'second generation' PPI. The aim of this article is to provide an update on the pharmacology and clinical profile of rabeprazole and its use in acid-related disorders, with a particular focus on its role in gastroesophageal reflux disease; in the treatment and prevention of duodenal and gastric ulcers and Zollinger-Ellison syndrome; in the therapy of the extraesophageal manifestations of gastroesophageal reflux disease (in particular the respiratory and ear, nose and throat ones); and in the eradication of Helicobacter pylori.

Heterogeneity of endoscopy negative heartburn: epidemiology and natural history.

It has now become clear that only about 40% or less of patients with heartburn and/or regurgitation have esophagitis, and that the majority of them lack visible distal esophageal mucosa breaks. These subjects are referred to as non-erosive gastroesophageal reflux disease (NERD) patients. It has been estimated that in the Western world at least one tenth of the general population has at least weekly heartburn. This proportion seems to be lower in Asia, while prevalence is rapidly increasing. Although it would be extremely useful to have prospective information regarding the fate of such patients, the natural history of NERD is largely unknown, and very few studies in the literature have addressed this issue. These studies are for the greater part old, not well conducted, and suffer from methodological drawbacks including ill-defined entry criteria. However, a review of these studies indicates that a consistent minority of NERD patients may develop erosive disease at an approximate rate of about 10% per year.

An uncommon cause of corrosive esophageal injury.

We present an unusual case of corrosive esophageal injury following liquid glue ingestion. The endoscopic findings were tissue sloughing and blackened appearance of the esophagogastric junction, due to caustic esophageal injuries following ingestion of glue containing toluene.

Biliary reflux and non-acid reflux are two distinct phenomena: a comparison between 24-hour multichannel intraesophageal impedance and bilirubin monitoring.

OBJECTIVE: Duodenogastroesophageal reflux (DGER) can greatly increase microscopic and macroscopic esophageal mucosal damage caused by acid. The aim of this study was simultaneously to assess the chemical composition of DGER by detecting bilirubin in the refluxate by means of Bilitec and describe its pH and physical properties by impedance monitoring, in order to prove that non-acid reflux and biliary reflux are two distinct phenomena. MATERIAL AND METHODS: Twenty patients with gastroesophageal reflux disease (GERD) with symptoms refractory to conventional proton-pump inhibitor (PPI) therapy or with atypical GERD symptoms were included in the study. All patients underwent upper gastrointestinal endoscopy and simultaneous Bilitec and intraeosophageal impedance (IIM) and pH monitoring. In the majority of patients (16/20), the tests were performed while assuming a standard PPI dose. RESULTS: Pathological bilirubin exposure, as defined by intraesophageal bilirubin absorbance above 0.14 for more than 3.9% of the time, was present in 9 cases, 6 of them with normal values of non-acid reflux, as detected by IIM. A pathological non-acid reflux, as defined by an IIM showing a percentage time with non-acid reflux greater than 1.4%, was observed in 5 patients, 2 of whom had no pathological biliary reflux, as detected by Bilitec. No correlation was found between the two indices, as expressed by an r-value of -0.12 (p>0.05). CONCLUSIONS: Our study confirms that biliary reflux and non-acid reflux as detected by Bilitec and by IIM, respectively, are two distinct phenomena that require different techniques in order to be assessed in humans.

Nongastroesophageal reflux disease-related infectious, inflammatory and injurious disorders of the esophagus.

PURPOSE OF REVIEW: To review recently published studies presenting novel and relevant information on some esophageal infectious, inflammatory and injurious diseases. RECENT FINDINGS: In the treatment of Candida esophagitis, fluconazole remains the treatment of choice, but clinical failures indicate new therapeutic opportunities, like two new echinocandins, micafungin and anidulafungin. Eosinophilic esophagitis is an increasingly recognized entity. New therapeutic insights come from a six-food elimination diet in children and from fluticasone propionate in adults; humanized monoclonal IgG antibody anti-interlukin-5, mepolizumab, has been shown to decrease eosinophilia and ameliorate symptoms. There has been some advance in microscopic characterization of lymphocytic esophagitis. Esophagitis is found to be present in 67% of patients with pemphigo vulgaris, in 32.3% of patients with systemic sclerosis and to be associated with thoracic neoplasias. In the case of caustic ingestion, endoscopic ultrasound with miniprobes has proven not to be better than videoendoscopy. Recent evidence shows that systemic steroids might even be harmful. Mitomycin C applied on fresh wounds is currently being evaluated. Stenting of the stricture has been proposed for contrasting esophageal remodeling. SUMMARY: These recent findings, together with a better understanding of diseases such as eosinophilic or lymphocytic esophagitis, allow new diagnostic and therapeutic approaches.

A review of rabeprazole in the treatment of acid-related diseases.

Rabeprazole is a proton pump inhibitor. Pharmacodynamic data show rabeprazole can achieve optimal acid suppression since the first administration and can maintain this advantage in the following days of therapy. Moreover, rabeprazole has the highest pKa (~ 5.0, the pH at which a drug becomes 50% protonated), and hence the molecule can be activated at higher pH levels much faster than other PPIs. Due to its peculiar catabolic pathway, ie, a prevalent metabolism through a non-enzymatic pathway, rabeprazole is less susceptible to the influence of genetic polymorphisms for CYP2C19, resulting in minor influences on its pharmacokinetics and pharmacodynamics. In terms of clinical efficacy, rabeprazole 20 mg uid or 10 mg bid produced healing rates at 8 weeks similar to those obtained with omeprazole 20 mg uid in erosive esophagitis patients, and in NERD patients doses of 10 or 20 mg are equivalent and both are better than placebo at 2 and 4 weeks. To prevent symptomatic relapse, on-demand strategy with rabeprazole 10 mg daily appears to be ideal, due to its rapidity of onset; results on NERD patients have documented its superiority over placebo. Continuous treatment, however, up to 5 years, seems to achieve better results than on-demand therapy, particularly in patients with esophagitis. It is debated whether in the latter halved doses (10 mg) are really equivalent to full dose (20 mg). Rabeprazole has been used with success in the treatment of some atypical GERD manifestations, such as dysphagia associated with GERD, GERD-related asthma and chest-pain, and in the therapy of Barrett's esophagus. Finally, rabeprazole achieves similar Helicobacter pylori eradication rates compared with omeprazole and lansoprazole when co-administrated with low or high doses of antibiotics (amoxicillin and clarithromycin). In addition, low doses of rabeprazole (10 mg/bid) may be effective in eradicating the pathogen.