Periendoscopic Care Continuum in Acute Cholangitis Caused By Common Bile Duct Stone.

Acute cholangitis (AC) is a biliary tract infection with in-hospital mortality rates reaching up to 14.7%. The underlying condition is biliary obstruction caused by benign and malignant etiologies, as well as bacteriobilia, with commom bile duct (CBD) stone being one of the most common causes. Currently, the diagnosis is validated using Tokyo Guidelines 2018 criteria. Acute cholangitis due to CBD stone should be managed in a comprehensive manner, i.e., periendoscopic care continuum, consisting of pre-endoscopic care, endoscopic management, and post-endoscopic care. Pre-endoscopic care is primarily comprised of supportive therapy, antibiotic administration, optimal timing of endoscopic retrograde cholangiopancreatography (ERCP), pre-ERCP preparation, and informed consent. Endoscopic management is biliary decompression with stone extraction facilitated via ERCP procedure. Selective biliary cannulation should be performed meticulously. Bile aspiration and minimal bile duct contrast injection should be done to minimize the worsening of biliary infection. Endoscopic biliary sphincterotomy, endoscopic papillary balloon dilatation, and/or endoscopic papillary large balloon dilatation are all safe procedures that can be used in AC. Special precautions must be undertaken in critical and severe acute cholangitis patients who may not tolerate bleeding, in whom endoscopic biliary sphincterotomy may be postponed to decrease the risk of bleeding, and biliary decompression may be only attempted without CBD stone extraction. Nasobiliary tubes and plastic biliary stents are equally effective and safe for patients who have only undergone biliary decompression. In post-endoscopic care, management of adverse events and observation of therapy response are mandatory.

Joint Asian Pacific Association of Gastroenterology (APAGE)-Asian Pacific Society of Digestive Endoscopy (APSDE) clinical practice guidelines on the use of non-invasive biomarkers for diagnosis of colorectal neoplasia.

Screening for colorectal cancer (CRC) is effective in reducing CRC related mortality. Current screening methods include endoscopy based and biomarker based approaches. This guideline is a joint official statement of the Asian Pacific Association of Gastroenterology (APAGE) and the Asian Pacific Society of Digestive Endoscopy (APSDE), developed in response to the increasing use of, and accumulating supportive evidence for the role of, non-invasive biomarkers for the diagnosis of CRC and its precursor lesions. A systematic review of 678 publications and a two stage Delphi consensus process involving 16 clinicians in various disciplines was undertaken to develop 32 evidence based and expert opinion based recommendations for the use of faecal immunochemical tests, faecal based tumour biomarkers or microbial biomarkers, and blood based tumour biomarkers for the detection of CRC and adenoma. Comprehensive up-to-date guidance is provided on indications, patient selection and strengths and limitations of each screening tool. Future research to inform clinical applications are discussed alongside objective measurement of research priorities. This joint APAGE-APSDE practice guideline is intended to provide an up-to-date guide to assist clinicians worldwide in utilising non-invasive biomarkers for CRC screening; it has particular salience for clinicians in the Asia-Pacific region.

Assessment of Circulating Tumor Cells in Colorectal Cancer as an Adjunctive Non-invasive Diagnostic Method.

BACKGROUND: Colorectal cancer (CRC) is a significant contributor to cancer-related morbidity and mortality. Biopsy remains the gold standard for CRC diagnosis, but invasive testing may not be preferred as an initial diagnostic procedure. Therefore, alternative non-invasive approaches are needed. Circulating tumor cells (CTC) present in the bloodstream have great potential as a non-invasive diagnostic marker for CRC patients. This study aimed to assess the diagnostic potential of CTC in CRC as an adjunctive diagnostic method using a subjective manual identification method and laser capture microdissection at 40x magnification. METHODS: A cross-sectional study was conducted on adult patients suspected to have CRC at Dr. Cipto Mangunkusumo National General Hospital, Jakarta, between November 2020 and March 2021. CTC analysis was performed using the negative selection immunomagnetic method with Easysep™ and the CD44 mesenchymal tumor marker. The identification and quantification of CTC were conducted manually and subjectively, with three repetitions of cell counting per field of view at 40x magnification. RESULTS: Of 80 subjects, 77.5% were diagnosed with CRC, while 7.5% and 15% exhibited adenomatous polyps and inflammatory/hyperplastic polyps, respectively. The diagnostic analysis of CTC for detecting CRC (compared to polyps) using a CTC cutoff point of >1.5 cells/mL suggested sensitivity, specificity, and positive predictive value (PPV) of 50%, 88.89%, and 93.94%. Additionally, the negative predictive value (NPV), as well as the positive and negative likelihood ratio (PLR and NLR) were 34.04%, 4.5, and 0.56, respectively. The subjective manual identification and quantification of CTC were performed at 40x magnification using laser capture microdissection. CONCLUSION: This study assessed the diagnostic potential of CTC examination in CRC as an adjunctive diagnostic method using the subjective manual identification method and laser capture microdissection at 40x magnification. Despite the limitations associated with subjective cell counting, the results showed 50% sensitivity and 88.89% specificity in diagnosing CRC. Further studies are needed to optimize the manual identification process and validate the clinical utility of CTC analysis in CRC patients.

Role of glycodeoxycholic acid to induce acute pancreatitis in Macaca nemestrina.

BACKGROUND: Acute pancreatitis exhibits a rapid clinical progression which makes it difficult to observe in human; hence, an experimental animal model is needed. This preliminary study performed an induction of acute pancreatitis using glycodeoxycholic acid (GDOC) in an experimental macaque model. METHODS: GDOC injections (initial dose of 11.20 mg/kg) were administered in an escalating manner at specific time points. The injection was given along the bilio-pancreatic duct, followed by measurement of vital signs, serum amylase-lipase, TNF-α, procalcitonin, oxidative stress parameters, and microscopic and macroscopic findings. RESULTS: The results indicated that acute pancreatitis occurred following induction with low-dose GDOC. Serum amylase and lipase levels increased with subsequent GDOC injections. Blood pressure and heart rate were elevated, indicating abdominal pain. Changes in TNF-α, procalcitonin, and oxidative stress values showed active inflammation. We observed histologic features of pancreatitis and as the dose increased, vasodilation of the splanchnic vasculatures was observed. CONCLUSIONS: Small dose GDOC injection in the bilio-pancreatic duct may have a role to induce acute pancreatitis in Macaca nemestrina.

One Year Survival of Extrahepatic Cholangiocarcinoma Patients Who Did Not Undergo Curative Resection and Paliative Chemotherapy and Its Associated Factors.

BACKGROUND: Extrahepatic cholangiocarcinoma is rare but fatal. Patients who come are usually already in the advanced stage that can not undergo curative resection and chemotherapy also seems to be very rarely done. The survival rate and its associated factors in Indonesia are unknown. This study aimed to identify 1-year survival of patients with extrahepatic cholangiocarcinoma without curative resection and palliative chemotherapy and its associated factors. METHODS: This is a cross-sectional study using medical records of extrahepatic cholangiocarcinoma (perihilar and distal) inpatient and outpatient patients at Cipto Mangunkusumo Hospital, Jakarta from January 2015 to March 2020, reviewed retrospectively. The following factors were analyzed in terms of mortality: metastasis, sepsis, hypoalbuminemia, serum bilirubin level, serum CA 19-9 level, billiary drainage, neutrophyl lympocyte ratio (NLR) and comorbid factors. RESULTS: 115 out of 144 patients were enrolled in this study with male proportion of 50.4%, and proportion of patients aged 65 years or above was 71.3%. 1 year survival rate was 10 % and median survival was 3 months (CI 95% 2.388-3.612)Multivariate analysis showed that only sepsis, unsuccessful or no prior biliary drainage and total bilirubin >19.8 mg/dl were independent predictors of mortality. CONCLUSION: 1 year survival of extrahepatic cholangiocarcinoma without curative resection and paliative chemotherapy was 10 %.Sepsis, unsuccessful or no prior bilirary drainage, and total biirubin >19.8 mg/dl  are factors significantly associated with shortened survival in malignant obstructive jaundice patients.

The impact of the coronavirus disease 2019 pandemic on gastroenterologists in Southeast Asia: A mixed-methods study.

BACKGROUND AND AIM: The coronavirus disease 2019 pandemic has impacted gastroenterology practices worldwide; however, its protracted effects within Southeast Asia were unknown. The primary aim of the study was to determine the impact of the pandemic on clinical demands including burnout among gastroenterologists within the region. The secondary aim was to identify risk factors for burnout and determine regional stressors. METHODS: This was a mixed-methods study. Gastroenterologists were surveyed electronically between September 1 and December 7, 2020, via gastroenterology and endoscopy societies of Brunei, Indonesia, Malaysia, Philippines, Singapore, and Thailand. Quantitative and qualitative data were collected. The 22-item Maslach Burnout Inventory-Human Services Survey (MBI-HSS) was used to detect burnout. Quantitative data were non-parametric; non-parametric methods were used for statistical comparisons. Logistic regression was used to determine risk factors for burnout. Content analysis method was used to analyze qualitative data. Ethical approval was obtained. RESULTS: A total of 73.0% reported that they were still significantly affected by the pandemic. Of these, 40.5% reported increased workload and 59.5% decreased workload. Statistically significant differences in weekly working hours, endoscopy, and inpatient volumes were present. No differences were observed in outpatient volumes, likely because of telemedicine. Burnout was common; however, 50.1% of gastroenterologists were unaware of or did not have access to mental health support. This, as well as depression, being a trainee, and public sector work, increased burnout risk significantly. CONCLUSION: The effects of the pandemic are multifaceted, and burnout is common among Southeast Asian gastroenterologists. Safeguards for mental health are suboptimal, and improvements are urgently needed.

The role of SpyGlass Direct Visualization System on Patient with Indeterminate biliary strictures: A case report.

Biliary strictures diagnosis has become a challenge where benign conditions could mimic a malignant process. Recently, SpyGlass DS overcame the limitations by allowing direct visualization of the biliary tree. A 65 years old Indian patient complaints of jaundice with total and direct bilirubin of 23.3 mg/dL and 16.2 mg/dL, respectively. Liver function test, gamma-glutamyltransferase and CA 19-9 were increased. Transabdominal ultrasound and abdominal CT supported dilatation of common bile duct (CBD) with abrupt narrowing showing periductal enhancement at supra pancreatic level and stricture. Endoscopic ultrasound showed intrahepatic CBD stricture with dilated proximal CBD and sludge ball. Endoscopic retrograde cholangiopancreatography showed mid CBD stricture. Although brush cytology results suggested low grade dysplasia and no definite evidence of malignancy, cholangioscopy using SpyGlass DS found nodularity with abnormal vascularity seen in mid of CBD suggesting malignancy, confirmed with histopathology as cholangiocarcinoma. We reported additional value of SpyGlass DS for detecting cholangiocarcinoma in an indeterminate biliary stricture patient.

Tocilizumab as a Treatment for 'Cytokine Storm Syndrome' in COVID-19: A Case Report.

Coronavirus disease 19 (COVID-19) which is caused by Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), has been a problem worldwide, particularly due to the high rate of transmission and wide range of clinical manifestations. Acute respiratory distress syndrome (ARDS) and multiorgan failure are the most common events observed in severe cases and can be fatal. Cytokine storm syndrome emerges as one of the possibilities for the development of ARDS and multiorgan failure in severe cases of COVID-19. This case report describes a case of a 53-year-old male patient who has been diagnosed with COVID-19. Further evaluation in this patient showed that there was a marked increase in IL-6 level in blood accompanied with hyperferritinemia, which was in accordance with the characteristic of cytokine storm syndrome. Patient was treated with tocilizumab, a monoclonal antibody and is an antagonist to IL-6 receptor. The binding between tocilizumab and IL-6 receptors effectively inhibit and manage cytokine storm syndrome. Although this case report reported the efficacy of tocilizumab in managing cytokine storm syndrome, tocilizumab has several adverse effects requiring close monitoring. Further clinical randomized control trial is required to evaluate the efficacy and safety of tocilizumab administration in participants with various clinical characteristics and greater number of subjects.

International consensus statements for endoscopic management of distal biliary stricture.

Distal biliary strictures (DBS) are common and may be caused by both malignant and benign pathologies. While endoscopic procedures play a major role in their management, a comprehensive review of the subject is still lacking. Our consensus statements were formulated by a group of expert Asian pancreatico-biliary interventional endoscopists, following a proposal from the Digestive Endoscopy Society of Taiwan, the Thai Association for Gastrointestinal Endoscopy, and the Tokyo Conference of Asian Pancreato-biliary Interventional Endoscopy. Based on a literature review utilizing Medline, Cochrane library, and Embase databases, a total of 19 consensus statements on DBS were made on diagnosis, endoscopic drainage, benign biliary stricture, malignant biliary stricture, and management of recurrent biliary obstruction and other complications. Our consensus statements provide comprehensive guidance for the endoscopic management of DBS.

Six-month Survival of Patients with Malignant Distal Biliary Stricture Following Endoscopic Biliary Stent Procedure and Its Associated Factors.

BACKGROUND: unresectable malignant distal biliary stricture patients require endoscopic biliary stent placement procedure. The survival rate and its associated factors in Indonesia are unknown. OBJECTIVES: To identify 6-month survival of patients with malignant distal biliary stricture following endoscopic biliary stent procedure and its associated factors. METHODS: a retrospective cohort study was conducted using medical records of patients with unresectable malignant distal biliary stricture, which involved caput of pancreas, ampulla of Vater or distal cholangiocarcinoma following endoscopic biliary stent procedure between June 2015 and August 2017 at Cipto Mangunkusumo National Central General Hospital. The cumulative survival was defined by using the Kaplan-Meier curve. Bivariate and multivariate analyses were performed using Cox regression of some factors including failure of biliary stent insertion, bleeding, sepsis, comorbidities, malnutrition, and serum albumin levels. RESULTS: out of total 120 subjects, 85 subjects died within 6 months following the stent procedure with a proportion of 180-day survival of 24% and a median survival of 81 days (CI 95%: 56-106 days). In bivariate analysis, factors of comorbidities, sepsis, malnutrition and albumin levels ≤ 3.0 g/dL had p values of < 0.25; while the subsequent multivariate analysis showed that albumin level of ≤ 3.0 g/dL had HR of 2.73 (CI 95%: 1.48 - 5.05; p = 0.001). CONCLUSION: the 6-month survival following endoscopic biliary stent procedure is 24% with a median survival of 81 days. Albumin level of ≤ 3.0 g/dL has a 2.73 times greater risk for 6-month mortality rate.

A Clinical and Procedural Guideline for Gastrointestinal Endoscopy Units during COVID-19 Pandemic Era.

The World Health Organization (WHO) has declared COVID-19 as global pandemic since there are tremendous growing numbers of confirmed cases for SARS-C0V-2 infection, the number of affected countries and high mortality rate. The global COVID-19 pandemic also will affect various aspects of health care including endoscopic service. The Indonesian Society for Digestive Endoscopy (ISDE), which provides a scope for doctors who perform endoscopic procedures, has developed a clinical and procedural guideline that may serve as a reference for doctors performing gastrointestinal endoscopy in Indonesia.

National Consensus on Management of Dyspepsia and Helicobacter pylori Infection.

Dyspepsia is one of numerous general complaints, which is commonly encountered by doctors of various disciplines. In daily practice, the complaint is not only limited for gastroenterologists. Knowledge on pathophysiology of dyspepsia have been developing continuously since a scientific investigation has been started in 1980's, which considers Helicobacter pylori as one of key factor in managing dyspepsia, either it is associated with ulcer or non-ulcer. The management of dyspepsia cannot be separated from the management of H. pylori and there is an additional new knowledge associated with definition, pathophysiology, diagnosis and treatment of both dyspepsia and H. pylori infection.This consensus document on the management of dyspepsia and H. pylori infection in Indonesia has been developed using the evidence-based medicine principles; therefore, it can be used as a reference for doctors in dealing with dyspepsia and H. pylori infection cases in their daily practice. It is expected that with the new consensus, doctors can provide greater service to their patients who have dyspepsia and H. pylori infection.

The Effects of Ramadhan Fasting on Clinical Symptoms in Patients with Gastroesophageal Reflux Disease.

AIM: to determine the effects of Ramadhan fasting on GERD symptoms. METHODS: a total of 130 GERD patients participated in this study. Patients were divided into two groups, i.e. those who performed Ramadhan fasting (n=66), and those who did not perform Ramadhan fasting (n=64). The evaluation was done using Indonesian version of GERD questionnaire (GERD-Q) between the two groups, and between Ramadhan month and non-Ramadhan month in the Ramadhan fasting group. RESULTS: there was a statistically significant difference (p<0.01) in the median of GERD-Q score in Ramadhan-fasting group subjects and non-Ramadhan-fasting group subjects (0 vs. 4). Moreover, a statistically significant difference (p<0.01) was also found in the median of GERD-Q score in Ramadhan-fasting group subjects and non-fasting group subjects (p<0.01). CONCLUSION: subjects in Ramadhan fasting group, GERD symptoms experienced less severe during fasting month (Ramadhan) than non-fasting month. During Ramadhan month, GERD symptoms were also milder in Ramadhan fasting group than those in non-fasting group subjects.

The role of per oral cholangiopancreatoscopy (POCPS) in complicated pancreaticobiliary disease.

A fifty-five year old female patient presented with jaundice, subfebrile fever and dark yellow urine since one month before admission. She lost weight 10 kilograms during one month. One day before admission to Ciptomangunkusumo General Hospital, she complained of worsened abdominal pain at right upper quadrant urging her to come to the emergency room. An abdominal examination revealed Murphy sign, mild hepatomegaly and deeply icteric sclera. Serum bilirubin was 21.8 mg/dl, alkaline phosphatase and gamma-glutamyltransferase levels were significantly elevated (1090 IU/L and 560 IU/L consecutively) while the transaminases were moderately high (ALT 80 U/L). The C-reactive protein was 555 mg/L. An abdominal ultrasound examination revealed dilatation of right and left intrahepatic bile duct and presence of common hepatic duct stone. Subsequent magnetic resonance imaging/magnetic cholangiopancreatography (MRI/MRCP) revealed intrahepatic bile duct dilatation, multiple CBD stone and benign stricture at common hepatic duct causing right and left intrahepatic bile duct obstruction.We assessed the patient as acute cholangitis and obstructive jaundice suspected to be caused by biliary duct stone then we performed endoscopic retrograde cholangiopancreatography (ERCP), we revealing stenosis at distal CBD, multiple CBD stone, giant stone in CHD and dilatation of bilateral IHBD. We performed CBD stone extraction then inserted biliary stent for drainage. Then we planned to do second ERCP with SpyGlassTM for giant stone extraction. After the first ERCP, the clinical condition of the patient improved and the bilirubin decreased to 10 mg/dL. In the next two weeks we performed a second ERCP to extract the giant stone with SpyGlass TM. However, after we inserted SpyGlassTM into the biliary duct, what we found were not as we expected before. We revealed that there was a mass in biliary duct and there was no CBD stone. We did the biopsy and inserted a new plastic stent (after removed the older one) to the common biliary duct. Surprisingly, the result of histopathology also supports our findings, which was the adenocarcinoma at common bile duct.

Present status of endoscopy, therapeutic endoscopy and the endoscopy training system in Indonesia.

Recently, Indonesia was ranked as the fourth most populous country in the world. Based on 2012 data, 85000 general practitioners and 25000 specialists are in service around the country. Gastrointestinal (GI) disease remains the most common finding in daily practise, in both outpatient and inpatient settings, and ranks fifth in causing mortality in Indonesia. Management of patients with GI disease involves all health-care levels with the main portion in primary health care. Some are managed by specialists in secondary health care or are referred to tertiary health care. GI endoscopy is one of the main diagnostic and therapeutic modalities in the management of GI disease. Development of GI endoscopy in Indonesia started before World War II and, today, many GI endoscopy procedures are conducted in Indonesia, both diagnostic and therapeutic. Based on August 2013 data, there are 515 GI endoscopists in Indonesia. Most GI endoscopists are competent in carrying out basic endoscopy procedures, whereas only a few carry out advanced endoscopy procedures, including therapeutic endoscopy. Recently, the GI endoscopy training system in Indonesia consists of basic GI endoscopy training of 3-6 months held at 10 GI endoscopy training centers. GI endoscopy training is also eligible as part of a fellowship program of consultant gastroenterologists held at six accredited fellowship centers in Indonesia. Indonesian Society for Digestive Endoscopy in collaboration with GI endoscopy training centers in Indonesia and overseas has been working to increase quality and number of GI endoscopists, covering both basic and advanced GI endoscopy procedures.

Expression of NF-kB and COX2 in colorectal cancer among native Indonesians: the role of inflammation in colorectal carcinogenesis.

AIM: to evaluate the expression of NF-kB and COX2 in native Indonesians with sporadic colorectal cancer (CRC). METHODS: we conducted a matched-pair case-control study by acquiring both CRC and tumor-adjacent normal tissues from the same subjects. CRC patients who underwent surgery at Cipto Mangunkusumo Hospital, Jakarta, or Hasan Sadikin Hospital, Bandung, were enrolled in the study. The specimens were immunohistologically stained with antibody directed against p65 (RelA) to assess NF-kB expression and against human COX2 protein to assess COX2 expression. RESULTS: sixty-seven specimens consisting of both CRC and tumor-adjacent normal tissues were analyzed. COX2 expression was positive in 39 CRC tissues (58.2%), but in only 19 tumor-adjacent normal tissues (28.4%; p=0.0002). NF-kB expression was positive in 47 CRC tissues (70.1%), but in only 27 tumor-adjacent normal tissues (40.3%; p<0.0001). CONCLUSION: inflammation plays a role in the carcinogenesis of sporadic CRC in native Indonesians. This support potential use of nonsteroidal anti-inflammatory drugs as chemopreventive agents for CRC.

Role of interventional endoscopic ultrasound in a developing country.

BACKGROUND/AIMS: Endoscopic ultrasound (EUS) has become an essential diagnostic and therapeutic tool. EUS was introduced in 2013 in Indonesia and is considered relatively new. This study aimed to describe the current role of interventional EUS at our hospital as a part of the Indonesian tertiary health center experience. METHODS: This retrospective study included all patients who underwent interventional EUS (n=94) at our center between January 2015 and December 2020. Patient characteristics, technical success, clinical success, and adverse events associated with each type of interventional EUS procedure were evaluated. RESULTS: Altogether, 94 interventional EUS procedures were performed at our center between 2015 and 2020 including 75 cases of EUS-guided biliary drainage (EUS-BD), 14 cases of EUS-guided pancreatic fluid drainage, and five cases of EUS-guided celiac plexus neurolysis. The technical and clinical success rates of EUS-BD were 98.6% and 52%, respectively. The technical success rate was 100% for both EUS-guided pancreatic fluid drainage and EUS-guided celiac plexus neurolysis. The adverse event rates were 10.6% and 7.1% for EUS-BD and EUS-guided pancreatic fluid drainage, respectively. CONCLUSION: EUS is an effective and safe tool for the treatment of gastrointestinal and biliary diseases. It has a low rate of adverse events, even in developing countries.

The Expressions of NF-κB, COX-2, Sp1, and c-Jun in Pancreatic Ductal Adenocarcinoma and Their Associations with Patient Survival.

Chronic inflammation is a crucial driver of carcinogenesis in pancreatic ductal adenocarcinoma (PDAC). Several studies have investigated the prognostic significance of cyclooxygenase-2 (COX-2) expression in PDAC patients, obtaining conflicting results. Nuclear factor kappa-B (NF-κB), specificity protein 1 (Sp1), and c-Jun are known as the transcription factors of the COX2 gene. This exploratory observational study investigated the association of the NF-κB, COX-2, Sp1, and c-Jun expressions with patient survival in PDAC. We used the immunohistochemical method to detect the PDAC tissue expressions of NF-κB (RelA/p65), COX-2, Sp1, and c-Jun. The expressions of these proteins were correlated with the overall survival (OS) and other clinicopathological characteristics of PDAC patients. We obtained 53 PDAC specimens from resections and biopsies. There were significant correlations between the four proteins' expressions in the PDAC tissues. The expression of the cytoplasmic (aHR = 0.31; 95% CI 0.11-0.90; p = 0.032) or nuclear NF-κB (aHR = 0.22; 95% CI 0.07-0.66; p = 0.007) was independently associated with a better prognosis in the PDAC patients. COX-2, Sp1, and c-Jun showed no significant association with a prognosis in the PDAC patients. The PDAC patients who expressed NF-κB had a better prognosis than the other patients, which suggests that the role of inflammation in PDAC is more complex than previously thought.

Management of dyspepsia and Helicobacter pylori infection: the 2022 Indonesian Consensus Report.

Dyspepsia still becomes a major challenge in upper gastrointestinal disease in Indonesia. This disease often correlated with Helicobacter pylori infection. However, the prevalence of this bacterium is generally low in Indonesia. Therefore, several considerations should be taken into consideration during the management of dyspepsia and H. pylori infection. "Management of dyspepsia and H. pylori infection in Indonesia: The Indonesian consensus report" comprises information gathered from 22 gastroenterology centers across Indonesia. The experts gathered to evolve a consensus, that consists of the statements, grades of recommendations, evidence levels, and rationales for the dyspepsia and H. pylori infection management for daily clinical practice. The report explains several aspects from the updated epidemiology information to comprehensive management therapy. After the experts worked together on all statements in the recommendations, the results are presented with the final agreement as a consensus to help clinicians in understanding, diagnosing, and treating dyspepsia and H. pylori infection patients in daily clinical practice in Indonesia.