Management of Helicobacter pylori infection-the Maastricht V/Florence Consensus Report.

Important progress has been made in the management of Helicobacter pylori infection and in this fifth edition of the Maastricht Consensus Report, key aspects related to the clinical role of H. pylori were re-evaluated in 2015. In the Maastricht V/Florence Consensus Conference, 43 experts from 24 countries examined new data related to H. pylori in five subdivided workshops: (1) Indications/Associations, (2) Diagnosis, (3) Treatment, (4) Prevention/Public Health, (5) H. pylori and the Gastric Microbiota. The results of the individual workshops were presented to a final consensus voting that included all participants. Recommendations are provided on the basis of the best available evidence and relevance to the management of H. pylori infection in the various clinical scenarios.

Covid-19: exploring the "new normal" in gastroenterology training.

The coronavirus disease 2019 (COVID-19) pandemic has led to unprecedented disruptions in fellowship training programs worldwide. In gastroenterology, the strain in healthcare service provision and the emphasis on preventing viral transmission has adversely impacted hands-on training opportunities, with trainees facing the constant pressure to meet training requirements under the continuous threat of viral transmission. Emerging evidence highlight the scale of the problem, specifically with regard to endoscopy competence due to cancellation of elective endoscopic procedures, provision of inpatient and outpatient consultative care as well as academic education and the mental well-being of trainees. As such, it has been necessary for trainees, trainers and training programs collectively to adapt to these challenges and incorporate novel and adaptive solutions to circumvent these training barriers. This review aims to summarise data on the global impact of COVID-19 on gastroenterology training and the practical interventions that could be implemented.

Does purgative preparation influence the diagnostic yield of small bowel video capsule endoscopy?: A meta-analysis.

OBJECTIVES: Video capsule endoscopy (VCE) is a useful tool in investigating small bowel pathology. However, the role of bowel preparation is controversial. Therefore, the aim of this study was to explore the role of bowel preparation and in particular its consequences on diagnostic yield in a meta-analysis of all relevant studies. METHODS: Extensive English-language medical literature searches were performed up to February 2008, using suitable keywords, looking for human studies that compared different modes of small bowel preparation (purgative vs. clear liquids diet). We examined the effects of this preparation on the following three primary end points, diagnostic yield (DY), small bowel visualization quality (SBVQ), and VCE completion rate (CR) by meta-analysis of relevant studies. RESULTS: A total of 12 eligible studies (6 prospective, 6 retrospective) were identified, including 16 sets of data relevant to our primary end points. There were significant differences between patients prepared with purgative vs. those prepared with clear liquids diet in DY (263 vs. 213 patients, respectively; OR (95% CI)=1.813 (1.251-2.628), P=0.002) and SBVQ (404 vs. 249 patients, respectively; OR (95% CI)=2.113 (1.252-3.566), P=0.005). There was no statistically significant difference regarding CR rate. Purgatives did not affect VCE gastric transit time (GTT) or VCE small bowel transit time (SBTT). CONCLUSIONS: Pooled data showed that in comparison to clear liquids diet, purgative bowel cleansing, before VCE, improves the SBVQ and increases the DY of the examination, but does not affect the VCE completion rate.

Video-capsule endoscopy gastric and small bowel transit time and completeness of the examination in patients with diabetes mellitus.

BACKGROUND: Small intestine video-capsule endoscopy examination in patients with diabetes mellitus may be incomplete due to delayed gastric emptying. AIM: To measure video-capsule endoscopy gastric and small bowel transit time and to assess the completeness of the examination in diabetes mellitus patients. METHODS: In this retrospective, case-control study, we examined capsule endoscopy videos from 29 consecutive diabetes mellitus patients. Fifty-eight matched for sex, type of preparation, age and reason for referral non-diabetic controls were selected from our video-capsule endoscopy database. Two independent experienced investigators measured transit times and assessed examinations' completeness. RESULTS: Video-capsule endoscopy gastric transit time was significantly longer in diabetes mellitus (87, 1-478 min) compared to non-diabetic patients (24, 4-108 min, p<0.001). The caecum was visualized in 20/29 (69%) diabetes mellitus and 52/58 (89.6%) non-diabetic controls (p=0.02). In 16 diabetes mellitus patients that video-capsule endoscopy reached the caecum, small bowel transit time was significantly shorter (261.2+/-55.5 min) compared to their 32 non-diabetic matched controls (302+/-62.7 min, p=0.03). CONCLUSIONS: Patients with type 2 diabetes mellitus have prolonged video-capsule endoscopy gastric transit time compared to non-diabetic patients. Prospective studies are required to complete our understanding of video-capsule endoscopy transit times in the setting of diabetes mellitus.

Colon neoplasia in patients with type 2 diabetes on metformin: A meta-analysis.

BACKGROUND: A growing body of evidence has suggested that metformin potentially reduces the risk of cancer. OBJECTIVE: We performed a meta-analysis of available studies to better define the effect of metformin on colon neoplasia (cancer and polyps) in patients with type 2 diabetes. METHODS: Medical literature searches for human studies were performed through December 2015, using suitable keywords. Pooled estimates were obtained using fixed or random-effects models. Heterogeneity between studies was evaluated with the Cochran Q test whereas the likelihood of publication bias was assessed by constructing funnel plots. Their symmetry was estimated by the Begg and Mazumdar adjusted rank correlation test and by the Egger's regression test. In addition subgroup and sensitivity analyses were performed. RESULTS: A total number of 709,980 patients, with type 2 diabetes, were included in 17 studies eligible for meta-analysis [1 RCT and 16 observational studies (13 cohort and 3 case-controls)]. The risk of colon neoplasia was significantly lower among metformin users than controls (non-metformin users) [pooled RRs (95% CI)=0.75 (0.65-0.87), test for overall effect Z=-3.95, p<0.001]. This observation applied separately for colon cancer [0.79 (0.69-0.91), Z=-3.34, p<0.001] and for colon polyps [0.58 (0.42-0.80), Z=-3.30, p<0.001]. CONCLUSION: This meta-analysis shows that the use of metformin in patients with type 2 diabetes is associated with significantly lower risk of colon neoplasia.

The association between Helicobacter pylori infection and inflammatory bowel disease based on meta-analysis.

BACKGROUND: In humans there are epidemiological data suggesting a protective effect of Helicobacter pylori (H. pylori) infection against the development of autoimmune diseases and in addition, there are laboratory data illustrating H. pylori's ability to induce immune tolerance and limit inflammatory responses. Thus, numerous observational studies have examined the association between H. pylori infection and inflammatory bowel disease (IBD) with various results. OBJECTIVE: We performed a meta-analysis of available studies to better define the association of H. pylori infection and IBD. METHODS: Medical literature searches for human studies were performed through September 2014, using suitable keywords. In each study the risk ratio (RR) of H. pylori infection in IBD patients vs controls was calculated and pooled estimates were obtained using fixed- or random-effects models as appropriate. Heterogeneity between studies was evaluated using Cochran Q test and I(2) statistics, whereas the likelihood of publication bias was assessed by constructing funnel plots. RESULTS: Thirty-three studies were eligible for meta-analysis, including 4400 IBD patients and 4763 controls. Overall 26.5% of IBD patients were positive for H. pylori infection, compared to 44.7% of individuals in the control group. There was significant heterogeneity in the included studies (Q = 137.2, df (Q) =32, I(2) ( )= 77%, p < 0.001) and therefore the random-effects model of meta-analysis was used. The obtained pool RR estimation was 0.62 (95% confidence interval (CI) 0.55-0.71, test for overall effect Z = -7.04, p < 0.001). There was no evidence of publication bias. CONCLUSION: The results of this meta-analysis showed a significant negative association between H. pylori infection and IBD that supports a possible protective benefit of H. pylori infection against the development of IBD.

The association between CagA status and the development of esophagitis after the eradication of Helicobacter pylori.

BACKGROUND: Strains of Helicobacter pylori with the cytotoxine-associated gene A (cagA) are linked to severe forms of gastroduodenal disease. Although eradication of H. pylori may predispose to the development of reflux esophagitis, the effects of CagA status on risk of esophagitis after successful H. pylori treatment are not known. METHODS: We studied 50 consecutive patients without esophagitis in whom H. pylori was eradicated successfully. CagA status was determined by immunoblotting sera from patients against H. pylori antigens. Patients underwent upper gastrointestinal endoscopy before eradication and 6, 12, 18, and 24 months after eradication or when reflux symptoms occurred. Biopsy specimens of the antrum and corpus were evaluated for gastritis before H. pylori eradication and at the end of the study. The sum of the scores for acute and chronic inflammation (both measured on a 0 [absent] to 3 [severe] scale) comprised the total gastritis severity score. RESULTS: In a multivariate proportional hazards regression analysis, positive CagA serology (hazard ratio [HR] = 10, 95% confidence interval [CI]: 1.3 to 81) and moderate-to-severe corpus gastritis (total severity score > or =4) before eradication (HR = 2.3, 95% CI: 1.2 to 6.1) were independent risk factors for the development of esophagitis after H. pylori eradication. CONCLUSION: Patients infected with strains of H. pylori that are cagA-positive are at increased risk of developing esophagitis after eradication of H. pylori.

Short-course therapy with amoxycillin-clarithromycin triple therapy for 10 days (ACT-10) eradicates Helicobacter pylori and heals duodenal ulcer. ACT-10 Study Group.

BACKGROUND: Whilst the role of Helicobacter pylori eradication in managing duodenal ulcers has been established, consensus regarding the ideal regimen has not been achieved. METHODS: Patients with H. pylori-positive active duodenal ulcer were randomly assigned to receive triple therapy with amoxycillin 1000 mg b.d. + clarithromycin 500 mg b.d. + omeprazole 20 mg daily for 10 days (ACT-10) or dual therapy with clarithromycin 500 mg t.d.s. + omeprazole 40 mg daily for 14 days (Dual). No additional acid suppression was provided following eradication therapy. Endoscopy, with biopsy for culture and histology, as well as 13C-urea breath testing (13C-UBT) were performed pre-treatment to assess H. pylori infection. H. pylori eradication was established at 4-6 weeks follow-up with culture (2 antral, 1 corpus biopsies), histology (2 antral biopsies), and 13C-UBT. Ulcer healing by endoscopy and change in clinical symptoms were also assessed at 4-6 weeks. RESULTS: Two hundred and sixty-seven (267) patients were randomized to ACT-10 (n = 137) or Dual therapy (n = 130). By per-protocol and intention-to-treat analyses, H. pylori eradication at 4-6 weeks follow-up was 91% (115/127) and 88% (120/136), respectively, for ACT-10 patients and 59% (68/115) and 55% (72/130), respectively, for Dual therapy patients (P < 0.001 for both analyses). Ulcer healing was high in both treatment groups: ACT-10, 93% (118/127) and 90% (122/136), respectively; and Dual therapy, 91% (104/114) and 85% (111/130), respectively. Pre-treatment resistance to clarithromycin was low (4%, 8/214) as compared to metronidazole resistance which was over 40%. Emergence of resistance to clarithromycin was observed in 2% of patients receiving ACT-10 and in 25% of those receiving Dual therapy. ACT-10 and Dual therapy patients experienced similar rates of drug-related adverse events (33% vs. 32%, respectively) and discontinuation from therapy due to an adverse event (1.5% vs. 5%, respectively). More than 90% of patients were compliant with each prescribed medication. CONCLUSION: In patients with active duodenal ulcer, a 10-day course of amoxycillin-clarithromycin-based triple therapy without additional acid suppression is highly effective in eradicating H. pylori and healing duodenal ulcer.

Gastroesophageal reflux presented with haemoptysis and carinal erythematous lesion resembling in situ carcinoma.

Gastroesophageal reflux (GER) is often associated with respiratory disorders. We report an unusual case of GER presented with haemoptysis. On fibreoptic bronchoscopy (FFB) a focal erythematous lesion of the mucosa of the main carina was found. Repeated FFB and biopsy excluded in situ neoplasm. Pharmacological treatment of GER with sisapride and ranitidine resulted in complete remission of the bronchial lesions. To the best of our knowledge haemoptysis with bronchoscopic lesions due to the gastroesophageal reflux has not been described previously.

Proliferating cell nuclear antigen (PCNA) immunostaining in Helicobacter pylori infection: impact of eradication.

Despite the fact that the association of Helicobacter pylori (H. pylori)with an increased risk of gastric cancer has been well documented, the exact mechanisms of this association have not been fully elucidated. The aim of the present prospective study was to contribute to the exploration of these mechanisms by studying the relationship between H. pylori infection and proliferating cell nuclear antigen (PCNA) immunostaining in endoscopic biopsies in gastric antrum. Furthermore, we examined the impact of H. pylorieradication on this relationship. We studied 28 H. pyloripositive patients and the results were compared with 22 endoscopically and histologically normal H. pylorinegative patients (control group) who were comparable to the H. pyloripositive group for age and sex. In addition all H. pyloripositive patients were examined before and after treatment aiming to eradicate H. pylori. In the H. pylori(+) patients the median PCNA index was 35 (range 8-58) and this was significantly higher than the respective number in the control group [5.5 (2 14), p<0.001]. In patients studied before and after successful eradication of H. pylori(n=10) the corresponding numbers were 35 (8-56) and 7 (4 13) (p<0.01) the latter not being significantly different from the control group of H. pylori(-)patients. On the contrary, in patients without successful H. pylori eradication (n=18) the PCNA indices before and after treatment were similar [35.5 (21-58) vs 31.5 (20-56)]. It is concluded that H. pyloriinfection alters the replication cycle of the gastric mucosa inducing hyperproliferation, which return towards normal after successful H. pylori eradication.

Enhancement of bowel sounds by wavelet-based filtering.

This paper evaluates the performance of an automatic method for structural decomposition, noise removal and enhancement of bowel sounds (BS), based on the wavelet transform. The proposed method combines multiresolution analysis with hard thresholding to compose a wavelet transform-based stationary-nonstationary (WTST-NST) filter, for enhanced separation of bowel sounds (BS) from superimposed noise. Quantitative and qualitative analysis of the experimental results, when applying the WTST-NST filter to BS recorded from controls and patients with gastrointestinal dysfunction, prove that the ability of the WTST-NST filter to remove noise and reveal the authentic structure of BS is excellent. By eliminating the need to record a noise reference signal, this method reduces hardware overhead when analysis of BS is the primary aim. The method is independent of subjective human judgement for selection of noise reference templates, is robust to different levels of signal interference, and, due to its simplicity, can easily be used in clinical medicine.

Small polyps found at sigmoidoscopy: are they significant?

In this study we prospectively examined the significance of small polyps found at screening flexible sigmoidoscopy and studied in particular, the possibility that hyperplastic polyps in the rectosigmoid can serve as potential markers for neoplastic polyps proximal to this area. During the last three years we performed sigmoidoscopy on 1500 patients. One hundred and five patients (7%) had one or more polyps in the rectosigmoid. Exclusion criteria were polyps of > 1 cm in size, a history of bleeding, inflammatory bowel disease or past polypectomy. After excluding 30 patients, 75/1500 (5%) patients with small polyps remained in the study. All these patients were submitted to total colonoscopy with removal of all polyps found. Histopathology showed that 45/75 (60%) patients had hyperplastic polyps and 30/75 (40%) had at least one adenomatous polyp. Among the 45 patients with hyperplastic polyps at flexible sigmoidoscopy, 16 (35.5%) had a more proximal adenomatous polyp. Nine of the 30 patients (30%) who had at least one adenomatous polyp in the rectosigmoid were found to have them more proximally. We conclude that a) size alone is not an accurate predictor of the histology of the polyp, b) because small polyps, either hyperplastic or adenomatous, in the rectosigmoid indicate a risk for adenomatous polyps more proximally, all patients with small polyps found during flexible sigmoidoscopy should be submitted to total colonoscopy.

Optimal dose of omeprazole in combination with amoxicillin in eradicating H. pylori and preventing relapses in duodenal ulcer patients.

BACKGROUND/AIMS: Triple therapy schemes, based on bismuth salts, eradicate H.pylori in a high percentage of duodenal ulcer (DU) patients. However, a simple and effective regime with a low complication rate is desirable. Previous studies have shown that the combination of Omeprazole (O) with an antibiotic (most commonly Amoxycillin [A]) is effective, but the optimal dose of O in this combination is not well defined. The aim of this study therefore was to address this subject. MATERIALS AND METHODS: The following four groups of patients were studied: group I (20mg O daily + 500mg A qid, n=18), group II (20mg O bid + 500mg A qid, n=17), group III (20mg O tid + 500mg A qid, n=18), group IV (20mg O qid + 500mg A qid, n=20). Patients were treated for two weeks with the above combinations. Endoscopy was performed four weeks after stopping treatment to check for H. pylori eradication and then one year later or when symptoms suggesting relapse occurred. RESULTS: Eradication rates were as follows; group I 6/18 (33.3%), group II 10/17 (58.8%), group III 15/18 (83.3%), group IV 17/20 (85%). The highest eradication rate was achieved in group IV which was significantly higher (P<0.001) than in all the other groups except for group III. After treatment, there was a total of 48 H. pylori (-) and 25 H. pylori (+) patients in the four groups of patients studied. Relapse occurred in 20/25 (80%) of the H. pylori (+) patients and in only 2/48 (4.16%) of the H. pylori (-) patients (P<0.001). CONCLUSIONS: a) The combination of Omeprazole and Amoxycillin is effective in eradicating H. pylori. It seems that in this combination 60 or 80mg of Omeprazole is equally effective in achieving high percentages of eradication. Eradication of H. pylori with this regime prevents duodenal ulcer recurrence.

Pancreatic duct width: its significance as a diagnostic criterion for pancreatic disease.

The significance of main pancreatic duct width in the diagnosis of pancreatic disease, was studied in 338 endoscopic retrograde pancreatographies. Two hundred and forty patients referred for suspected biliary disease had normal pancreatograms (Group 1), 60 had pancreatic carcinoma (Group 2) and 38 had a history and pancreatogram compatible with chronic pancreatitis (Group 3). After categorizing patients by decade, in group 1 the effect of aging on the pancreatic duct width in the head, body and tail (F5,234 > 3.71, p < 0.003) was pronounced, especially after the fifth decade. There was a significant difference between groups 1, 2 and 3 in terms of the width of the main pancreatic duct in all three parts of the pancreas (F2,325 > 42.24, p < 0.001). The upper range of normal pancreatic duct width was 8.0 mm, 4.0 mm and 2.4 mm in the head, body and tail, respectively. Abnormal ductograms were wider than the normal ranges in the head, body and tail of the pancreas in 14%, 49% and 59% (p < 0.001) of the patients, respectively. Establishing normal ranges of the pancreatic duct width may help in the diagnosis of pancreatic disease. Measurements in the body and tail, as compared with the head, are a more sensitive indicator of pancreatic duct dilation.

Bismuth: effects on gastritis and peptic ulcer.

The healing properties of colloidal bismuth subcitrate (CBS) on peptic ulcer are well established and several studies have shown that healing with CBS is associated with a lower relapse rate than that produced by H2-receptor antagonists. The recent observation that CBS is effective against Campylobacter pylori has shed light on this because recent studies have shown that eradication of C. pylori by CBS leads to resolution of the associated gastritis and this may explain the low relapse rates. CBS is also effective in C. pylori positive patients with non ulcer dyspepsia (NUD) in whom clearance of these organisms from the stomach is associated with significant improvement of the associated gastritis and symptoms.

Current concepts in the management of Helicobacter pylori infection: the Maastricht III Consensus Report.

BACKGROUND: Guidelines on the management of Helicobacter pylori, which cover indications for management and treatment strategies, were produced in 2000. AIMS: To update the guidelines at the European Helicobacter Study Group (EHSG) Third Maastricht Consensus Conference, with emphasis on the potential of H pylori eradication for the prevention of gastric cancer. RESULTS: Eradication of H pylori infection is recommended in (a) patients with gastroduodenal diseases such as peptic ulcer disease and low grade gastric, mucosa associated lymphoid tissue (MALT) lymphoma; (b) patients with atrophic gastritis; (c) first degree relatives of patients with gastric cancer; (d) patients with unexplained iron deficiency anaemia; and (e) patients with chronic idiopathic thrombocytopenic purpura. Recurrent abdominal pain in children is not an indication for a "test and treat" strategy if other causes are excluded. Eradication of H pylori infection (a) does not cause gastro-oesophageal reflux disease (GORD) or exacerbate GORD, and (b) may prevent peptic ulcer in patients who are naïve users of non-steroidal anti-inflammatory drugs (NSAIDs). H pylori eradication is less effective than proton pump inhibitor (PPI) treatment in preventing ulcer recurrence in long term NSAID users. In primary care a test and treat strategy using a non-invasive test is recommended in adult patients with persistent dyspepsia under the age of 45. The urea breath test, stool antigen tests, and serological kits with a high accuracy are non-invasive tests which should be used for the diagnosis of H pylori infection. Triple therapy using a PPI with clarithromycin and amoxicillin or metronidazole given twice daily remains the recommended first choice treatment. Bismuth-containing quadruple therapy, if available, is also a first choice treatment option. Rescue treatment should be based on antimicrobial susceptibility. CONCLUSION: The global burden of gastric cancer is considerable but varies geographically. Eradication of H pylori infection has the potential to reduce the risk of gastric cancer development.

Impact of H. pylori infection on the management of dyspepsia.

This review article refers to the impact which Helicobacter pylori infection has on the management of dyspepsia. The answer to the question of whether H. pylori eradication is clinically useful in dyspeptic patients or not remains a controversial and debatable subject. Nonetheless, the recent Maastricht 2 - 2000 Consensus Report, taking into account all the available data so far, concluded that a 'test-and-treat' approach to dyspepsia should be used in adult patients with persistent dyspepsia under the age of 45 years (the cutoff age may vary locally), having excluded those with predominantly gastroesophageal reflux disease symptoms, nonsteroidal anti-inflammatory drug users, and patients with alarm symptoms or a family history of gastric cancer.

Ambulatory esophageal pH recording in gastroesophageal reflux: relevance to the development of esophagitis.

In a group of 60 patients with symptomatic gastroesophageal reflux (GER), we carried out upper gastrointestinal (GI) endoscopy and 24-h ambulatory esophageal pH monitoring to assess the relationship between acid reflux and esophagitis. The results of 24-h pH measurement were compared with those of 15 asymptomatic control subjects who were studied with ambulatory 24-h esophageal pH monitoring only. Thirty-two patients (53.3%) had a normal esophagus macroscopically, and 28 patients (46.7%) had some degree of esophagitis. There was no significant difference between the two groups with and without esophagitis, regarding male:female ratio, age, and duration of symptoms. The group with esophagitis was more symptomatic (p less than 0.001) than the group without, and differed significantly in relation to all pH variables, i.e., number of GER episodes per hour, duration of mucosal exposure to acid (pH less than 4), and number of GER episodes requiring more than 5 min to clear per hour for the upright, supine, and 24-h periods, compared with the control group (p less than 0.001) and the group without esophagitis (p less than 0.001). In the group with esophagitis, comparison of the above pH variables in the upright and supine periods showed significantly higher values in the upright than in the supine period for the total number of reflux episodes per hour (p less than 0.001) and the number of episodes greater than 5 min/h (p less than 0.05). We conclude that the presence of esophagitis is related to both frequency and duration of GER episodes. Our findings also stress the importance of daytime acid exposure in the pathogenesis of esophagitis.

Detection of an increased incidence of early gastric cancer in patients with intestinal metaplasia type III who are closely followed up.

Because early gastric cancer is associated with a much better prognosis than advanced disease, its diagnosis is important. Over a 12 year period (1976-87), a progressive increase in the incidence of early gastric cancer was observed. Twenty four of the 718 (3.3%) consecutive gastric resections for gastric cancer in this period were in patients with early gastric cancer. Six of the 24 were diagnosed in the first six year period (1976-81) and 18 in the second six year period (1982-87) (p less than 0.01). This increase was observed during the prospective phase of the study, when all patients diagnosed on initial biopsy specimen as showing type III intestinal metaplasia underwent follow up endoscopy and biopsy at six to 12 month intervals. Eleven of the 18 with early gastric cancer detected in this period were diagnosed as a direct result of this follow up. We conclude that early gastric cancer can be diagnosed with increasing frequency if patients with type III intestinal metaplasia are closely followed endoscopically.