Introduction

Underwater endoscopic mucosal resection (U-EMR) is an emerging technique in the management of superficial nonampullary duodenal epithelial tumours (SNADETs). Nevertheless, particularly in Western centers, its application has not been comprehensively assessed.

Aims & Methods

Our aim was to compare the efficacy and safety of U-EMR versus conventional EMR (C-EMR) for the endoscopic treatment of SNADETs.
Retrospective case-control study that analyzed all patients who underwent duodenal EMR in a tertiary reference center, between 2015 and 2022. SNADETs ≥10 mm removed by U-EMR or C-EMR were included. Primary endpoint was residual/recurrent adenoma rate (RAR). Secondary outcomes were rates of technical success, en bloc resection, and adverse events (AE).

Results

A total of 40 duodenal adenomas (31 patients) were included (U-EMR n=18; C-EMR n=22). Median lesion size was 16.5 ± 13.3 mm. Lesions were predominantly IIa (47.5%) and IIa+c (20%) - Paris classification. Most lesions were in the second portion of duodenum (n=35).
Groups were similar regarding age, gender and lesion size. There were no significantly statistically differences between groups regarding technical success (100% U-EMR vs. 90.9% C-EMR, p=0.19) and en bloc resection rate (44.4% U-EMR vs. 54.2% C-EMR, p=0.53). RAR was higher in the C-EMR group (n=6/20, 30% vs. n=1/10, 10%, p=0.22), although without statistically significance. Post-EMR defects were more commonly closed in U-EMR group (83.3% vs. 45.5%, p <0.05). Peri-procedural AE rate (bleeding n=2 [11.1%] U-EMR vs. bleeding n=3 [13.6%] C-EMR, p=0.81) was similar between groups. There were no delayed complications in the U-EMR group while in the C-EMR group there were 2 cases of bleeding (0% vs. 9.1%, p= 0.19).

Conclusion

In our study, compared to C-EMR, U-EMR showed similar RAR and safety, highlighting its role as a feasible therapeutic option for the management of SNADETs.

Introduction

​Gastric lesions associated with Helicobacter pylori, eradication issues and problems of its sometimes-insufficient effectiveness continue to remain one of the most pressing topics in modern healthcare.

Aims & Methods

The analysis aimed to assess the usage, efficacy, and safety of initial empirical treatment for H. pylori infection in Azerbaijan.
​Data were collected at e-CRF AEG-REDCap from the European Registry on Helicobacter pylori Management (Hp-EuReg) and quality reviewed from January 2020 to May 2023. All treatment-naïve cases were assessed for effectiveness by modified intention-to-treat (mITT), per-protocol (PP) analyses, and a separate multivariate analysis was performed.

Results

The study included 3,898 patients (67% reported dyspepsia). In 1.9% of patients, at least one type of allergy was reported (1.6% to penicillin). A total of 226 patients (5.8%) received concurrent medication: PPI (5.1% on demand, 0.1% daily), aceltylsalicylic acid (1.2% on demand, 0.2% daily), NSAIDs (1.3% on demand), statins (1.2% on demand, 0.1% daily). The most frequent indication for treatment was dyspepsia with normal endoscopy in 2,610 patients (67%). In total, 3,853 (99%) patients were diagnosed pre-treatment using the rapid urease test, which was the most frequently used. The following tests were likewise used in a lower number of cases: monoclonal stool antigen test (MSAT)(0.7%) and polyclonal stool antigen test (0.1%). In 2,661 (68%) cases a MSAT was used, being the most frequent post-treatment confirmation method. Additionally, in 55 (1.4%) cases an invasive method, that is endoscopy, was performed, to confirm the eradication. First-line empirical treatment prescriptions and mITT effectiveness by treatment schemes is presented in Table 1.
Triple regimens were the most frequently prescribed in over 3,000 (82%) patients, where the PPI-C+A treatment scheme represented 54% of the total of first-line prescriptions. Treatment length varied from 14 days in 56% of cases, 10 days in 27%, and 7 days in 17%. Following 14-day treatments prescriptions achieved optimal (>90%) mITT effectiveness: PPI-C+A (94%), PPI-C+M (97%), PPI-C+M+ B (96%) and PPI-C+A+B (98%). Following schemes also provided optimal results when combined with standard-dose (i.e., 40 mg omeprazole equivalent twice a day) PPIs: PPI-A+Tc (100%) and PPI-C+A+B (96%). Additionally, prescriptions concomitantly administered with high-dose (i.e., 80 mg omeprazole equivalent twice a day) PPIs provided also over 90% eradication rates: PPI-C+A (94%), PPI-C+M (97%), PPI-C+M+B(100%) and PPI-C+A+B (99%). Compliance with treatment was over 90% in the vast majority of cases. The incidence of at least one adverse event was reported in 12% of cases.
Table 1. Most frequent first-line empirical treatment prescriptions and modified intention-to-treat effectiveness in Azerbaijan.

Conclusion

The prescribed H. pylori eradication regimens during the period 2020–2023 in Azerbaijan adhered only partially to the Maastricht VI recommendations; however, most of first-line empirical therapies achieved high (≥90%) cure rates, providing a good safety profile.

Introduction

The emergence of antimicrobial resistant Helicobacter pylori (H. pylori) has impacted treatment success rates. Local audits of prescription patterns and eradication rates are necessary to assess treatment efficacy and compliance with clinical guidelines. The first Irish consensus guidelines on the management of H. pylori were published in 2017. Clarithromycin-amoxicillin triple therapy (CTT) or bismuth quadruple therapy (BQT) were the recommended first-line options. Other key recommendations included extending treatment durations to 14 days and the use of high-dose proton pump inhibitors (PPIs).

Aims & Methods

This study aimed to (i) investigate first-line H. pylori prescription patterns and cure rates over a 10-year period in Ireland, and (ii) evaluate the impact of the first Irish consensus guidelines on these trends. Data were collected at e-CRF AEG-REDCap from the European Registry on Helicobacter pylori Management (Hp-EuReg) and quality reviewed from 2013 to 2022. All treatment-naïve cases were assessed for effectiveness by modified intention-to-treat (mITT) analysis. Multivariate analysis was performed using a logistic regression model to evaluate the relationship between mITT rates and age, sex, indication, compliance, PPI dose and treatment duration.

Results

In all, data from 1,000 patients (mean age 50±15 years; 54% (n=536) female) were included in the analysis, from those 78% (n=784) were from Tallaght University Hospital, Dublin and 22% (n=216) were from Beacon Hospital, Dublin. The most common indication was dyspepsia (92%; n=920), followed by duodenal ulcer and gastric ulcer (2%; n=20 and 1%; n=10, respectively). CTT was the most common first-line treatment (88%; n=880). BQT represented 1.7% (n=17) of prescriptions. Of the reported treatment durations (n=998), 87% (n=868) were for 14 days, 4.5% (n=45) were for 10 days and 8.5% (n=85) were for 7 days. Of the reported PPI dose prescribed (n=999), 86% (n=860) were high (i.e., 80 mg omeprazole equivalent twice daily), 0.9% (n=9) were standard (i.e., 40 mg omeprazole equivalent twice daily), and 13% (n=130) were low (i.e., 20 mg omeprazole equivalent twice daily).

The eradication rate was 80.1% (95% confidence interval (CI) 77.5-82.5%) overall and 81.4% (95% CI 78.9-83.7%) for CTT. Multivariate analysis revealed that good compliance and the use of high dose PPI were significantly associated with higher overall mITT rates (odds ratio (OR) 4.5, 95% CI 1.4-14.2, p<0.05 and OR 1.9, 95% CI 1.2-2.8, p< 0.005, respectively) and CTT mITT rates (OR 4.2, 95% CI 1.2-14.2, p<0.05 and OR 1.9, 95% CI 1.1-3.2, p<0.05, respectively).

Following publication of the Irish consensus guidelines in 2017, prescriptions for 14 days therapy increased from 39% (n=82/208) pre-2017 to 99% (n=786/790; p<0.0001) and the use of high dose PPI increased from 37% (n=77/207) pre-2017 to 99% (n=783/792; p<0.0001). In line with this, overall eradication rates significantly increased from 74.5% (95% CI 68.2-80.0%) pre-2017 to 81.6% (95% CI 78.7-84.1%; p<0.05). CTT eradication rates significantly increased from 75.7% (95% CI 68.2-81.8%) pre-2017 to 82.6% (95% CI 79.6-85.1%; p<0.05).

Conclusion

CTT was the most frequently prescribed first-line therapy between 2013-2022. BQT was rarely prescribed, reflecting difficulty accessing bismuth in Ireland. While treatment success increased following publication of the Irish consensus guidelines, cure rates remain below 90%. Alternative first-line treatment strategies are required in the Irish healthcare setting.

Clinical Case Summary

Introduction: Sarcoidosis is a multi-systemic disorder of unknown etiology that primarily involves the pulmonary system. Nevertheless, a diagnosis can be challenging for clinicians because of the potential for almost any organ to be affected. Hepatic granulomas occur in 50-65% of patients with systemic sarcoidosis, while isolated hepatic sarcoidosis is rare.
Aims & Methods: A 50-year-old Montenegrin female patient was consulted by a gastroenterologist due to multiple focal lesions open etiology in the liver and spleen detected on routine ultrasound examination.
Results: Laboratory results showed normal complete blood count, total bilirubin 11.1 µmol/L, aspartate-aminotransferase 35 U/L, alanine-aminotransferase 25 U/L, gamma-glutamyl transferase 247 U/L, pancreatic amylase 40 U/L, and lipase 23 U/L. Tumor markers were in range: carcinoembryonic antigen (CEA), cancer antigen (CA) 19-9, alpha fetoprotein (AFP), CA 72-4, except CA 15-3, which was slightly elevated. Increased activity of serum angiotensin-converting enzyme was shown. Viral and serological tests for hepatotropic viruses and autoimmune liver diseases were negative. Imaging methods performed were: Multi-Slice Computer Tomography (MSCT) of the lungs, abdomen and pelvis, Nuclear Magnetic Resonance of the abdomen with Magnetic Resonance Cholangiopancreatography (MRCP), mammography, upper endoscopy and colonoscopy, but these did not provide an answer to the primary cause of the focal lesion. In the end, a liver biopsy was performed, where non–caseous granulomas were described and a diagnosis of sarcoidosis was established.
Conclusion: The patient had isolated sarcoidosis of the liver and spleen, as no granulomatous abnormalities were identified in other organs. The patient showed a remarkable clinical response to corticosteroid therapy. Isolated hepatic and splenic sarcoidosis should be considered in asymptomatic patients with hepatosplenomegaly and suspected metastatic disease.

References

1. Grunewald J, Grutters JC, Arkema EV, Saketkoo LA, Moller DR, Müller-Quernheim J. Sarcoidosis. Nat Rev Dis Primers. 2019 Jul 4;5(1):45. doi: 10.1038/s41572-019-0096-x. Erratum in: Nat Rev Dis Primers. 2019;5(1):49
2. Franzen DP, Brutsche M, Nilsson J, Böni C, Daccord C, Distler O, Elsener D, Funke-Chambour M, Gruner C, Hayward-Könnecke H, Hostettler KE, Kündig T, Ribi C, Seebach JD, Seeger H, Vrugt B, Kolios AGA. Sarcoidosis - a multisystem disease. Swiss Med Wkly. 2022;152:w30049

Disclosure

This abstract was presented at the 11^th Congress of North Macedonian Society of Gastroenterohepatology with international participation held from June 9-11, 2023 in Ohrid, North Macedonia.

Introduction

Recurrence of Crohn’s disease (CD) after ileocolic resection is common. However, reliable non-invasive monitoring methods are lacking, for instance, the use of faecal calprotectin (FC) has showed inconsistent results in this subgroup of patients.

Aims & Methods

The aim of this study was to evaluate clinical and biochemical factors associated with post-operative endoscopic recurrence in CD patients.
Retrospective single-center study including patients with CD who underwent ileocolonoscopy for CD surveillance, after ileocolic resection. The patients’ clinical status was evaluated through Harvey-Bradshaw index (HBI), with clinical remission considered as ≤ 4 points. Biochemical parameters included erythrocyte sedimentation rate (ESR), c-reactive protein (CRP) and FC. Clinical and biochemical parameters were evaluated in the 6 months prior to ileocolonoscopy. Post-operative endoscopic recurrence was defined as a Rutgeerts score ≥ i2b.

Results

A total of 81 patients and 121 ileocolonoscopies were included. Most patients were female (55.6%), with a mean age of 48±13 years. Regarding the Montreal classification, 37 patients had ileal disease (45.7%) and 44 ileocolonic disease (54.3%); 9 patients had nonstricturing, nonpenetrating disease (11.1%), 35 stricturing (43.2%) and 37 penetrating disease (45.7%). Nineteen patients had perianal disease (23.5%). The mean time between the surgery and the endoscopic evaluation was 135±79 months. Post-operative endoscopic recurrence was observed in 52 ileocolonoscopies (43.0%).
Symptomatic patients (HBI > 4 points) were 11 times more likely to have post-operative endoscopic recurrence (OR 10.686, 95%CI 2.930-38.974, p<0.001). Those with post-operative endoscopic recurrence had a significantly higher FC values (median 189 vs 69 µg/g, p<0.001) and higher ESR values (median 14 vs 9 mm, p=0.002). In fact, patients with FC values ≥ 150 µg/g and those with ESR values > 12 mm were 4 and 3 times more likely to have post-operative endoscopic recurrence (OR 3.654, 95%CI 1.605-8.316, p=0.002 and OR 3.059, 95%CI 1.397-6.696, p=0.005, respectively). The presence of post-operative endoscopic recurrence was not associated with CRP values (median 2.9 vs 2.9 mg/L, p=0.466), and neither with mean time between the surgery and the endoscopic evaluation (mean 126±83 vs 142±75 months, p=0.263).

Conclusion

The presence of symptoms (HBI > 4 points), FC values ≥ 150 µg/g and ESR values > 12 mm was associated with post-operative endoscopic recurrence in CD. Therefore, the HBI, FC and ESR values can be used to monitor CD patients after ileocolic resection, and prompt endoscopic evaluation should be performed in those with HBI > 4 points, FC values ≥ 150 µg/g and/or ESR values > 12 mm.

Introduction

In recent years, propofol has become the sedative of choice for gastrointestinal endoscopy. Despite large cohort studies demonstrating its safety and effectiveness, the adoption of Non-Anesthesiologist Administration of Propofol (NAAP) in clinical practice still faces numerous challenges, both in Europe and globally. Consequently, propofol-based sedation remains largely in the hands of anesthesia professionals.

Aims & Methods

This study was conducted in two phases. Initially, a preliminary analysis was carried out to compare adverse event (AE) rates between NAAP and Anesthesiologist Administration of Propofol (AAP) at a tertiary academic center (San Raffaele Hospital, Milan, Italy). In the second phase, potential cost savings from implementing NAAP over AAP at the hospital, local, and national levels were examined.
Propensity score matching (PSM), based on age, sex, body mass index (BMI), and ASA Physical Status Classification System score, was used to compare the two cohorts. A 3-year budget impact model (BIM) was implemented based on the annual volume of outpatient endoscopy procedures performed at San Raffaele Hospital and estimates of the Italian adult population by Italian National Institute of Statistics (ISTAT).

Results

From May 2019 to October 2021, 2,721 patients who underwent esophagogastroduodenoscopy (EGD) (2,439 NAAP and 282 AAP) and 2,748 who underwent colonoscopy (2,491 NAAP and 257 AAP) in outpatient setting were enrolled. Only diagnostic procedures were included. After PSM, the EGD cohort included 282 patients under NAAP and 188 under AAP, while the colonoscopy cohort consisted of 256 patients under NAAP and 174 under AAP. No significant differences in AE rates were observed between the groups in both the EGD (overall: NAAP 1.1% vs AAP 0.8%, p=0.815; after PSM: NAAP 0.4% vs. AAP 1.0%, p=0.452) and colonoscopy cohorts (overall: NAAP 1.7% vs AAP 3.5%, p=0.202; after PSM: NAAP 3.5% vs. AAP 0.6%, p=0.249). All AEs were managed without leading to major or long-term sequelae.
According to the BIM, a complete implementation of NAAP instead of AAP for patients classified as ASA 1 and 2 would lead to financial savings of €851,649 at our hospital, €8.3 million for the Local Health Authority of Milan, €19.8 million for the Lombardy region, and €124.7 million for the Italian National Health System over the triennium 2023-2025.

Conclusion

NAAP is a safe sedation modality for outpatient gastrointestinal endoscopy, with AE rates comparable to those of AAP. Its widespread implementation, at the expense of AAP, could result in savings exceeding €120 million for the Italian National Health System over the triennium 2023-2025.

References

NAAP is a safe sedation modality with AE rates comparable to AAP. The widespread implementation of NAAP, rather than reliance on anesthesiologist-led propofol sedation, could result in savings exceeding €120 million for the Italian National Health System over the triennium 2023-2025.