Introduction

Antibiotic resistance is the leading cause of failure in the eradication of Helicobacter pylori (H. pylori) infection. In addition to general overuse and misuse of antibiotics, the repetition of the same therapy regimen further promotes the prevalence of resistant H. pylori strains. Molecular PCR techniques have enabled clinicians to tailor the treatment according to the antibiotic sensitivity of specific H. pylori. For the first time, the Maastricht VI Consensus has made a statement regarding the implementation of PCR.

Aims & Methods

Our aim was to assess the effectiveness of tailored therapy implementation in eradicating H. pylori infection evaluating the data from a multicentric, prospective registry of the clinical practice of European gastroenterologists in the management of H. pylori infection (Hp-EuReg). All H. pylori-infected and PCR-diagnosed patients registered until December 2023 at e-CRF AEG-REDCap were included. Treatment effectiveness was analysed per protocol (accounting only those adherent cases and those with a result either as success or failure to treatment). Effectiveness >85% was considered as satisfactory and >90% as optimal.

Results

A total of 265 patients from XX European countries were tested using the molecular PCR method, 203 (77%) cases on gastric tissue and 62 (23%) on stools. . The effectiveness of tailored therapy in treatment-naïve patients was 95%, while the eradication rate in the rescue (from 2^nd to 6^th) line was 86%. In the first line, the most common prescribed regimens were quadruple-clarithromycin+amoxicillin+metronidazole (C+A+M) therapy, followed by single-capsule quadruple therapy with metronidazole+tetracycline+bismuth (M+T+B), with an eradication rate of 95% and 97%,respectively. In the rescue line, the most common prescribed regimen was single-capsule quadruple therapy with M+T+B (achieving 87% effectiveness by PP), followed by quadruple C+A+M therapy (94%), triple-amoxicilin+metronidazole (A+M) (93%), and triple levofloxacin+amoxicilin (L+A) therapy (91%) (Table). Clarithromycin and fluoroquinolone resistance rates in the first line were 31% and 33%, respectively; while in rescue line, they were reported higher, that is 63% and 52%; respectively.
Table. Most frequent PCR-guided treatments prescriptions and per protocol effectiveness in Europe.

Conclusion

PCR-guided tailored therapy showed a consistent optimal (>90%) effectiveness in all therapy lines and prescriptions. This indicates that clarithromycin-based therapy can still be a reasonable treatment choice even in regions with high clarithromycin resistance rate, provided that pretreatment H. pylori antibiotic sensitivity is assessed.

Disclosure

Olga P. Nyssen received research funding from Mayoly and Allergan. Javier P. Gisbert served as speaker, consultant, and advisory member for or received research funding from Mayoly, Allergan, Diasorin, Gebro Pharma, and Richen.

Introduction

EUS-guided Gallbladder Drainage (EUS-GBD) with Lumen Apposing Metal Stent (LAMS) is a standard treatment for management of acute cholecystitis (AC) in unfit-for-surgery patients. Gallbladder Perforation is standardly considered as a contraindication to EUS-GBD.

Aims & Methods

This series aims at exploring outcomes of EUS-GBD in patients with AC and contained perforation (cp-AC).
All consecutive patients undergoing EUS-GBD in a single tertiary institution between 2020 and 2024 were enrolled in a prospective registry (PROTECT, ClinicalTrials.gov NCT04813055). Patients with cp-AC were included in this series, when presenting gallbladder wall rupture with adjacent encapsulated fluid collections. Baseline demographics and technical details were registered together with Technical success, Clinical success, Adverse Events (AEs), Recurrence and Survival evaluated every 60 days.

Results

From a prospective cohort of 48 EUS-GBD, 19 patients presented with cp-AC (median age 71 [62-78], male 42.1%, Charlson Comorbidity Index of 8 [7-9.8]). Acute cholecystitis was iatrogenic in 79% of these cases (ERCP with metal stenting in 14 and TACE in 1). Reason to avoid surgery was underlying malignancy in 89.5% and comorbidities in 15.8%. Amongst underlying malignancies, the most frequent one was Pancreatic Adenocarcinoma.
Ascites was present in 26.3% of cases. All procedures were performed transduodenally, with an operative luminal space of 31 [25 – 36] mm and a median tract thickness of 6 [5-8] mm.
A 10 mm Hot Axios LAMS was used in 95% of cases, and the release was free-hand in 89% and over-the-wire after former distention in 11% of cases. Antibiotic prophylaxis and coaxial double-pigtail plastic stents were adopted in 95% of cases.
Technical success was 100%. Clinical success was 94.7%, with a statistically significant 7-days reduction of white blood cells (p=0.0017 ) and C Reactive Protein (p=0.0067) .
AEs were registered in 21% of cases, severe/fatal in 11%.
Of note, 2 AEs (1 fatal) were related to additional attempts of draining liver abscesses adjacent to the GBD.
Five patients (27%) underwent additional endoscopic procedures for peroral cholecystoscopy, GBD clearance and LAMS removal, while 2 (11%) patients experienced uneventful LAMS migration.
Median hospital stay was 8 [6-13] days and median time to chemotherapy was 26 [19-56] days for those who were candidate to oncological treatment (N=10).
After a median follow-up of 254 [56-454] days, no AC recurrence was registered.

Conclusion

In the context of AC, contained perforation with adjacent collections does not seem to represent a contraindication to EUS-GBD with LAMS, despite the additional complexity related to a thicker interluminal distance. Management of large adjacent abscesses should involve multidisciplinary management and might require percutaneous drainage.

Clinical Case Summary

Drug-induced liver injury is an adverse effect of many pharmaceutical agents. Alverine citrate, an antispasmodic agent found in the fixed-dose combination Meteospasmyl (alverine citrate and simethicone), is widely used in functional gastrointestinal disorders. To date, only three cases are published in the literature. We report a case, with strong evidence, including a rechallenge confirming the causality.
Patient Observation: A 43-year-old woman presented with biliary-type abdominal pain. Her medical history was limited to hypertension treated with bisoprolol with no alcohol use or recent medication. Abdominal ultrasound revealed uncomplicated cholelithiasis; liver tests were normal. Alverine citrate was prescribed for symptomatic relief. Within two weeks, she developed jaundice and fatigue with a normal clinical examination. Blood tests showed severe hepatocellular injury: ALT and AST were 22× and 39× ULN, bilirubin was 274 µmol/L, and GGT/ALP were mildly elevated. Viral and autoimmune panels were negative. Imaging excluded biliary obstruction. Liver biopsy revealed portal inflammation with eosinophilic infiltrates, suggestive of immunoallergic hepatitis. The discontinuation of the drug led to normalization of liver enzymes. 3 years later, the patient was inadvertently re-exposed to alverine citrate, triggering a reproducible episode of acute hepatitis, thereby confirming causality. Diagnostic probability was assessed with the RUCAM score (12, "highly probable") and Naranjo scale (8, "probable"). Only three prior cases of alverine citrate-induced hepatitis, none of which reported a confirmed rechallenge. Although liver biopsy is not routinely required in DILI, it was essential here for diagnostic clarification.
Alverine citrate should be recognized as a rare cause of acute hepatitis. This case confirms its hepatotoxic potential and underscores the importance of early recognition and drug withdrawal to prevent recurrence.

References

1. RUCAM Scale: https://clincasequest.hospital/rucam-scale/
2. Naranjo Scale: https://proeurodilinet.eu/wp-content/uploads/2019/03/Causality-assessment-training-course-15-MARCH-.pdf
3. Couzigou P et al. Hepatitis and Alverine Citrate. J Hepatol. 1997. https://www.sciencedirect.com/science/article/abs/pii/S0168827897801870
4. Turkish case report. Turk J Gastroenterol. 2004. https://pubmed.ncbi.nlm.nih.gov/15259090/
5. Korean case report. Korean J Hepatol. 2010. https://pubmed.ncbi.nlm.nih.gov/20375645/
6. Simethicone safety review. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4033443/
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