Introduction

Helicobacter pylori (H. pylori) infection is a significant contributing factor of gastric cancer. Despite advances in early detection and endoscopic resection, metachronous neoplasms still pose a risk. The impact of H. pylori eradication on preventing metachronous gastric cancer remains debated, with its underlying mechanisms unclear. This study aimed to investigate immunohistological changes in gastric mucosa after H. pylori eradication and identify mechanisms preventing metachronous recurrence.

Aims & Methods

Patients diagnosed with early gastric cancer and H. pylori infection, who underwent endoscopic resection, were included. 36 cases of metachronous neoplasms occurring after eradication (metachronous group) were compared to an equal number of controls matched for age, sex, atrophy, and metaplasia (control group). Histological features and immunohistochemical staining for T cell markers (CD3, CD4, CD8), and immune exhaustion markers (Foxp3, PD-L1) were evaluated.

Results

In the control group, chronic inflammation, neutrophil infiltration, glandular atrophy, and intestinal metaplasia in the gastric mucosa significantly improved following H. pylori eradication. However, in the metachronous recurrence group, improvement was observed only in chronic inflammation and neutrophil infiltration. CD3 cell counts increased in both groups after eradication, but CD8 and CD8/CD3 ratios saw an increase only in the control group. Additionally, the CD4/CD3 ratio and PD-L1/CD4 expression significantly decreased after H. pylori eradication in the control group but not in the metachronous group.
In the subgroup analysis of the metachronous cancer group, which consists of cases with recurrent lesion cancer, CD8, PD-L1, and PD-L1/CD4 ratios showed significant differences when compared to the control group.

Conclusion

H. pylori eradication may prevent metachronous recurrence in early gastric cancer by improving histologic inflammation and recovering immune system.

Introduction

The global prevalence of Helicobacter pylori (HP) infection is almost 43% and affects almost 18% of Italians [1, 2]. The literature describes several endoscopic signs detectable during upper-GI endoscopy that may predict HP status [3]; however, in clinical practice, random biopsies according to the Sydney system are still widely used for its determination.

Aims & Methods

The aim of our study is to investigate the role of Regular arrangement of collecting venules (RAC) assessment, during upper-GI endoscopies, for predicting HP status. We conducted a monocentric prospective study including patients who underwent upper-GI endoscopy for any indications from August 2024 to February 2025. Upper-GI endoscopies were performed according to standard of care [4], with high-definition scopes and after adequate cleaning [5]. Exclusion criteria were autoimmune gastritis, antibiotics within the previous 4 weeks, gastric surgery, previous endoscopic submucosal resection, upper-GI neoplasms, age <18 years, severe liver/kidney disease and previous known HP infection. Every procedure was performed by 6 endoscopists trained in recognition of all typical endoscopic signs of healthy stomach or HP infection: RAC, fundic gland polyps, linear streaks, hematin spots and diffuse redness prior to data collection. HP infection was investigated by histological evaluation by bioptic sampling, obtained according to the Sydney criteria.

Results

From 429 enrolled patients, 244 patients were included, according to inclusion criteria (M 124, 50.8%, median age 54.9, IQR 41.9-65.0). The prevalence of H. pylori infection was 15.5% (38/244). The presence of RAC in both greater and lesser curvature was observed in 63.1% (154/244) of cases, gland polyps in 19.6% (48/244), linear streaks in 15.5% (38/244), hematin spots in 15.9% (39/244) and diffuse redness in 9% (22/244). The presence of RAC, gland polyps and diffuse redness were significantly associated with higher prevalence of HP infection (p<0.001). The best performance was obtained from the presence of RAC in both greater and lesser curvature (AUROC 0.808, p<0.001) with a sensitivity (SEN), specificity (SPE), NPV and PPV respectively of 82.7% (64.2-94.1), 78.8% (72.3-84.4), 96,2% (92-98.3) and 40.8% (33.3-48.7). At multivariate analysis it confirmed to be related to HP-negative status (p=0.01, OR 0.04 95%CI: 0.005-0.481). Lastly, the presence of RAC showed a higher performance in males (AUROC 0.836, SEN 86.6% 59.5-98.3, SPE 80.6% 71.4-87.9, NPV 97.1% 90.3-99.2, PPV 44.1% 33.4-55.3) and in young patients (AUROC 0.846, SEN 80% 51.9-95.6, SPE 89.2% 81.1-94.7, NPV 96.2% 90.1-98.6, PPV 56.7% 40.9-71.3). As expected, the presence of RAC required a very short observation time (29.3 ± 11.0 versus 34.7 ± 11.7 seconds; p=0,001).

Conclusion

The presence of RAC in both the greater and lesser curvatures is the most important and reliable indicator of HP-negative status, and the time required for the evaluation is minimal. Our findings may represent a first step toward avoiding unnecessary random biopsies, promoting a more accurate endoscopic examination focused on the careful assessment of the gastric mucosa

References

1. Chen YC, et al. Global Prevalence of Helicobacter pylori Infection and Incidence of Gastric Cancer Between 1980 and 2022. Gastroenterology, 2024
2. Zullo A, et al. Upper Endoscopy in Patients with Extra-Oesophageal Reflux Symptoms: A Multicentre Study. GE Port J Gastroenterol, 2020
3. Seo JY, et al. Predicting Helicobacter pylori infection from endoscopic features. Korean J Intern Med, 2024
4. Bisschops R, et al. Performance measures for upper gastrointestinal endoscopy: a European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative. Endoscopy, 2016
5. Manfredi G, et al. Premedication with simethicone and N-acetylcysteine for improving mucosal visibility during upper gastrointestinal endoscopy in a Western population. Endosc Int Open, 2021

Introduction

The effectiveness of anti-Helicobacter pylori treatment decreases as therapy failure accumulates. Different consensuses recommend knowing the regional performance of therapeutic regimens to achieve better eradication results in real clinical practice.

Aims & Methods

To evaluate the effectiveness of empirical therapy in second and subsequent treatment lines in Brazil.
Real-life, multicenter, prospective, non-interventional registry evaluating outcomes of H. pylori management by Brazilian gastroenterologists (Hp-BrazilReg, WorldHpReg’s partner). Data were registered at e-CRF AEG-RedCap from March 2022 to October 2024. The effectiveness was evaluated by modified intention-to-treat (mITT) analysis. Data were subject to quality review.

Results

​572 patients, with a mean age of 52 years, 64% women, were evaluated. The main treatment indications were dyspepsia (64%) and gastroduodenal ulcer (9.2%). 386 (67%) patients received a second-line therapy, and 186 (32%) received third-line or subsequent therapy. Low-dose (between 4.5 and 27 mg of omeprazole equivalent BID), standard-dose (between 32 and 40 mg of omeprazole equivalent BID), and high-dose (between 54 and 128 mg of omeprazole BID) proton pump inhibitor (PPIs) were used in 40%, 10%, and 24%, respectively. Vonoprazan (VPZ) 20 mg BID, was used in 26% of cases. With the second-line treatment, the overall eradication rate was 74%. The most frequently used regimen was the triple therapy with PPI+amoxicillin+levofloxacin for 10-14 days, in 55% of the patients. This regimen, recommended as an alternative by the Brazilian Consensus, achieved an eradication rate of 84% (14 days) and 55% (10 days). By adding bismuth to this same 14-day regimen the effectiveness increased to 100% (p=0.016). Regarding the third-line, the regimen containing PPI-bismuth-tetracycline-metronidazole was used in 24% of the cases, achieving 87% mITT cure rate. Within the fourth-line, dual therapy including amoxicillin-VPZ was the most common regimen (33%), achieving 100% eradication, followed by bismuth quadruple therapy with PPI+bismuth+amoxicillin+rifabutin (14%), showing 100% effectiveness. Dual therapy with VPZ+amoxicillin was also the most used regimen in the fifth-line and subsequent treatment lines, encompassing 43% of the cases, and achieving also 100% effectiveness. Overall, 23% of the patients presented mild adverse events being nausea the most frequent (14%), and compliance was 99%.

Conclusion

In Brazil, the overall effectiveness of second-line therapy showed suboptimal (≤90%) cure rate; however, the combination of bismuth-amoxicillin-levofloxacin prescribed for 14 days reported successful effectiveness. In the third-line, the classical bismuth-quadruple therapy with metronidazole-tetracycline provided encouraging results (87%). Alternatively, dual therapy with VPZ and amoxicillin and rifabutin-based bismuth quadruple therapy showed promising results in third- and fifth-line rescue treatment.