Introduction

Trisomy and tetrasomy 18 are genetic aberrations characterized by the presence of one or two additional copies of chromosome 18 within a subset or in the entirety of cellular components. This genomic anomaly is a prevalent karyotypic irregularity in extra nodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma), which is a type of lymphoma that originates from mucosa-associated lymphoid tissue in various organs, including the stomach, lungs, eyes, and thyroid. In previous investigation, we examined 146 patients with MALT lymphoma of the stomach who underwent FISH analysis for t (11, 18) translocation¹. However, the importance of trisomy and tetrasomy 18 in gastric MALT lymphoma is not fully understood because of the lack of long-term patient monitoring focused on genetic abnormalities. Therefore, in this study, we extended our investigation by tracking the same cohort of patients for an additional period exceeding 5 years to analyze the long-term prognosis of patients with gastric MALT lymphoma harboring trisomy/tetrasomy 18.

Aims & Methods

The objective of this study was to clarify the long-term prognosis of patients with gastric mucosa-associated lymphoid tissue (MALT) lymphoma with additional copies of MALT1. In this multicenter retrospective study, we enrolled 145 patients with gastric MALT lymphoma who underwent fluorescence in situ hybridization (FISH) analysis to detect t (11;18) translocation.

Results

The patient cohort was divided into three groups: Group A (n = 87), comprising individuals devoid of the t (11;18) translocation or extra MALT1 copies; Group B (n = 27), encompassing patients characterized by the presence of the t (11;18) translocation; and Group C (n = 31), including patients with extra MALT1 copies. The clinical outcomes in each cohort were collected. Over the course of a mean follow-up of 8.5 ± 4.2 years, one patient died of progressive MALT lymphoma, while 15 patients died due to etiologies unrelated to lymphoma. The progression or relapse of MALT lymphoma was observed in 11 patients: three in Group A, two in Group B, and six in Group C. In Groups A, B, and C, the 10-year overall survival rates were 82.5%, 93.8%, and 86.4%, respectively, and the 10-year event-free survival rates were 96.1%, 96.0%, and 82.9%, respectively. The event-free survival rate in Group C was significantly lower than that in Group A. However, no differences were observed in the 10-year event-free survival rates among individuals limited to stage I or II₁ disease (equivalent to excluding patients with stage IV disease in this study, as there were no patients with stage II₂), with rates of 98.6%, 95.8%, and 92.3% for Groups A, B, and C, respectively.

Conclusion

The presence of extra copies of MALT1 was identified as an inferior prognostic determinant of event-free survival.

References

1.Iwamuro, M. et al. Management of gastric mucosa-associated lymphoid tissue lymphoma in patients with extra copies of the MALT1 gene. World J. Gastroenterol. 23, 6155–6163 (2017).

Clinical Case Summary

A 28-year-old patient presented with recurrent episodes of overt gastrointestinal bleeding, requiring multiple blood transfusions over the past two months (5 units of packed red blood cells). Despite undergoing UGI endoscopy and colonoscopy twice at other medical centers, no abnormalities were detected. CT enterography with CT angiography yielded normal results. To further investigate, the patient underwent antegrade and retrograde power spiral enteroscopy, revealing gross active bleeding from a site of hookworm bite in the jejunum. Following the procedure, the patient was discharged with antihelminthic therapy. However, a week later, he experienced abdominal pain, difficulty passing stools, intermittent rectal bleeding again, and low-grade fever. A relook sigmoidoscopy revealed a large hematoma with intraluminal compression in the sigmoid colon. CT scan confirmed a localized sealed-off perforation along with the hematoma. Management included percutaneous aspiration of the hematoma, intravenous antibiotics, and repeat blood transfusion. Anti-helminthic therapy continued, and the patient recovered completely after approximately four weeks which was confirmed by sigmoidoscopy. The mechanism of this sigmoid colon hematoma involves potential mechanical injury by the overtube's spiral tip during insertion or manipulation. Although the localized perforation was sealed off in this case, the preceding bleeding and drop in hemoglobin complicated the initial treatment plan. Considering such technical challenges, the equipment and technology have now been withdrawn globally by the manufacturer. Close monitoring of patient symptoms, and vital signs, and prompt discontinuation of the procedure in case of discomfort or pain are crucial in preventing such complications. As advanced endoscopic techniques become more prevalent, maintaining a cautious approach towards technology and addressing complications promptly is essential for ensuring patient safety and effective care

Introduction

Hemorrhoidal disease (HD) is the most common pathology in proctology, with an estimated prevalence of between 4.4% and 39%. It can be managed in a variety of ways: hygienic-dietary measures, medical, instrumental or surgical treatment. The latter is considered especially after failure of medical and instrumental treatment.

Aims & Methods

Aims : The aim of our study is to report our experience with Milligan and Morgan technique in the management of hemorrhoidal disease.

Materials and methods: This was a monocentric retrospective descriptive-analytical study conducted over a 12-year period: from January 2011 to January 2023. The data studied were age, sex, clinical manifestations, stage of HD on proctological examination and therapeutic data. All patients who underwent Milligan and Morgan hemorrhoidectomy (MMH) and presented with stage IV and III hemorrhoids (after failure of instrumental treatment) were included in our study. Excluded were asymptomatic patients, patients with surgical contraindications and other stages treated by non-surgical means. The statistical study was carried out using IBM-SPSS 20.0 software. The chi-2 test was used to compare categorical variables.

Results

468 patients were enrolled during the study period. The mean age of this population was 41 years (22-71). The sex ratio M/F was 2,1. Clinical expression was dominated by rectal discharge in 246 patients (74%), proctalgia in 132 patients (28%), anal pruritus in 119 patients (25%) and anal oozing in 56 patients (12%). Proctological examination revealed stage IV haemorrhoids in 201 patients (43%) and stage III haemorrhoids in 267 patients (57%). 25 patients (5.3%) had an associated anal fissure. Anemia was present in 341 patients (72.8%), with a mean hemoglobin value of 7.8 g/dl. Transfusion was required in 65 patients (14%) who presented with severe anemia of less than 7g/dl. Colonoscopy was indicated in 87 patients (18.5%) over the age of 45 with rectal bleeding, and in 42 patients (9%) with a history of digestive cancer. Milligan and Morgan's indication was stage III hemorrhoids with severe anemia in 65 patients (14%), after failure of infrared photocoagulation in 194 patients (41.4%); after failure of HAL-RAR treatment n=8 (1.7%) and stage IV hemorrhoids in 201 patients (43%). The procedure performed was a hemorrhoidectomy.An open pedicle MMH type was performed. Patients with an associated anal fissure (5.3%) underwent the Bellan procedure in addition to hemorrhoidectomy. Immediate post-operative complications included post-operative pain in all our patients, urinary retention in 31 patients (6.6%), significant post-operative bleeding in 2 patients (0.5%) treated by electrocoagulation in the OR, and minimal post-operative bleeding in 117 patients (25%) treated by compression bandaging. The latter was reported in 43 patients (36.7%) with stage III hemorrhoids and 74 patients (63.2%) with stage IV hemorrhoids. This difference was statistically significant (p<0.001). Late complications included delayed healing in 9 patients (1.9%), 4 of whom were diabetic, anal stenosis in 5 patients (1%), requiring sphincterotomy combined with anoplasty in 3 patients, and finger dilatation in 2 patients. Anal stenosis was reported in 4 patients who did not undergo postoperative digital rectal examination and 1 patient who did. This difference is statistically significant p=0.03.

Conclusion

MMH remains the gold standard for the treatment of hemorrhoidal disease. The results are satisfactory, especially in the long term. Post-hemorrhoidectomy anal stenosis remains the most serious complication.

Introduction

Type I gastric neuroendocrine tumors (T1-GNETs) are caused by auto-immune gastritis and often occur in multiple lesions. Although endoscopic resection, such as endoscopic submucosal dissection (ESD), is often used for treatment of a small number of T1-GNET, antrectomy is also performed for multiple lesions. However, to date, the efficacy of antrectomy remains unclear.

Aims & Methods

Type I gastric neuroendocrine tumors (T1-GNETs) are caused by auto-immune gastritis and often occur in multiple lesions. Although endoscopic resection, such as endoscopic submucosal dissection (ESD), is often used for treatment of a small number of T1-GNET, antrectomy is also performed for multiple lesions. However, to date, the efficacy of antrectomy remains unclear.

Results

The median age of all patients was 54 years (range, 44–67 years). The ratio of male to female patients was 2:5. The number of tumors preoperatively observed in endoscopy was <10 in two patients, 10–20 in one, and >20 in four. The median size of largest tumor was 6 mm (range, 4–8 mm). Antrectomy was performed in three patients as initial treatment and in four as additional treatment after ESD. The number of tumors pathologically evaluated in resected specimens was <10 in four patients, 10–20 in two, and >20 in one. All tumors were limited to the submucosa. The median diameter of the largest tumor was 5 mm (range, 1.5–8 mm). The median gastrin levels significantly decreased from 3900 pg/mL (range, 2400–8000 pg/mL) to 73 pg/mL (range, 26–120 pg/mL) after antrectomy. Regarding postoperative assessment, tumor regression was observed in one patient and disappearance was observed in six at the follow-up endoscopy. The median period between antrectomy and tumor disappearance was 20 months (range, 5–49 months). No recurrence or cause-specific death occurred in all patients, with a median follow-up period of 48 months (range, 24–60 months).

Conclusion

Based on our findings, antrectomy does not only control local disease but also may lead to prevention of recurrence and regression of tumor persistence. Antrectomy was an effective treatment that could avoid total gastrectomy in patients with multiple T1-GNETs.

References

NCCN Clinical Practice Guidelines in Oncology: Neuroendocrine Tumors Version 2.2016

Introduction

H. pylori infection has affected approximately 50% of the world’s population with the rates being higher in developing countries than in developed ones. Conventional proton-pump inhibitors (PPIs) have been used as first-line treatment for this condition. However, potassium competitive acid blockers (PCABs) were recently developed which may offer beneficial effects than PPIs.

Aims & Methods

This meta-analysis aims to assess the effectiveness of Potassium competitive acid-blocker against Proton pump inhibitors for the eradication of H. pylori among adults with H. pylori infection.
Electronic search of randomized controlled trials comparing H pylori eradication rate of P-CAB and PPI-based therapy was done. Quality assessment used the Modified Cochrane risk-of-bias tool, and statistical analysis was performed using ReviewManager 5.4.1

Results

Fifteen RCTs with 4129 participants who received H pylori eradication therapy comparing potassium competitive acid blockers (Tegoprazan, Vonoprazan, and YH808) with proton pump inhibitors were analyzed. H. pylori eradication rate of potassium competitive acid blocker-based therapy was higher than that of PPI-based triple therapy RR 1.04, CI 1.10-1.18, P < 0.05. Subgroup analysis showed that PCABs based regimens had significantly higher eradication rates than PPI in treatment naive patients (RR 1.14, 95% CI 1.1-1.18, pP < 0.05 ) and that Vonoprazan based regimen in particular had superior eradication rates compared to PPI based regiments (RR 1.16 95% CI 1.12-1.20 P < 0.05). No significant differences were seen between the Tegoprazan and YH4808 groups compared to the PPI group. Adverse events were also lower in the PCAB group compared to the PPI group.

Conclusion

A significant challenge that is being faced by current PPIs include nocturnal acid reflux despite treatment with twice daily PPI, and additional dosage of H2-receptor blocker at bedtime which deters successful control of gastritis under PPI treatment.Our study shows that potassium competitive acid blockers are effective and have significantly higher eradication rates compared to PPI, with lower incidence of adverse events.

References

Yu, K. et al. (2020). Randomized clinical trial: tegoprazan, a novel potassium competitive acid blocker or lansoprazole in the treatment of gastric ulcer. Aliment PHarmacol Ther. 2020 Sept;52 (5);789-797
Tan, N. et al. (2023). Efficacy and safety of keverprazan compared with lansoprazole win the treatment of duodenal ulcer: a phase III, randomized double blind multicenter trial. Clinical and Translational Gastroenterology. 2023 Jul; 14(7)
Kim, J. et al. (2023). Efficacy of tegoprazan-based bismuth quadruple therapy compared with bismuth quadruple therapy for Helicobacter pylori infection: A randomized, double-blind, active-controlled study. Helicobacter. 2023 June; 28(3)
Zhou, S. et al. (2023). Keverprazan, a novel potassium-competitive acid blocker: Single ascending dose safety, tolerability, pharmacokinetics, pharmacodynamics and food effect in healthy subjects. European Journal of Pharmacetucial Sciences 190(1)2023;2-12
Zhou, B. et al. (2023). Vonoprazan-amoxicillin dual therapy for Helicobacter pylori eradication: A systematic review and meta-analysis of randomized controlled trials. Saudi J Gastroenterol.2023 Nov-Dec; 29(6): 347–357.
Yang, C. et al. (2022). Effectiveness and safety of vonoprazan-based regimen for Helicobacter pylori eradication: A meta-analysis of randomized clinical trials. J Clin Pharm Ther. 2022 Jul;47(7):897-904

Disclosure

authors have no conflict of interest

Introduction

Acute upper gastrointestinal (UGI) bleeding is a common medical emergency among the elderly. There is limited data on the management and outcomes of non-variceal UGI bleeding in the elderly in India.

Aims & Methods

We aimed to study clinical presentation, endoscopic findings, and outcomes in elderly patients with acute non-variceal UGI bleeding. All elderly patients (≥ 60 years of age) who presented with acute UGI bleed and were admitted for the same from 2021 to 2022 were retrospectively analysed. Baseline characteristics, blood transfusions before and after endoscopy, endoscopic diagnosis and therapy, AIMS65 score, complete Rockall score, and outcomes such as in-hospital re-bleeding and mortality were recorded.

Results

Of the 399 patients who had acute non-variceal UGI bleed, 309 patients aged <60 years were excluded. Of the 90 patients studied, the mean age of presentation was 69.8 ± 7.35 years, with 81.1% males. The most common presentation was melena (30%). Forty-one (45.5%) patients had a history of antiplatelet and anticoagulant use. The most common endoscopic finding was gastric ulcer (54.4%), followed by duodenal ulcer (22.2%), gastroesophageal junction ulcer (7.7%), Mallory-Weiss tear (6.6%), duodenal diverticular bleed (2.2%). The majority of ulcers were Forrest III (43.3%), followed by Forrest IIa (23.3%) and IIc (18.3%). Around 65% of patients with non-variceal UGI bleeds did not require endotherapy. Dual endotherapy was done in 25.5.5% of patients. Triple endotherapy was done in two patients. AIMS65 score was 1 in 50% of patients and 2 in 24.5% of patients. The majority (81.1%) of patients had a complete Rockall score of 3-7, indicating a moderate risk of re-bleeding and mortality. All the 90 patients were discharged without any mortality.

Conclusion

Our study showed that gastric ulcer was the most common cause of acute non-variceal UGI bleeding in the elderly, and melena was the most common presentation. Early endoscopic therapy may reduce blood transfusion requirements, in-hospital re-bleeding, and mortality.

Introduction

The use of proton pump inhibitors (PPIs) has increased in many Western countries over the past decades. This may reflect the increasing prevalence of symptoms of gastroesophageal reflux disease (GERD) and prophylactic PPI use against gastroduodenal ulcers and haemorrhage induced by non-steroid anti-inflammatory drugs (NSAIDs) or acetylsalicylic acid. However, increasing PPI use against functional or uninvestigated dyspepsia and other inappropriate prescription have previously been documented and may also have contributed to the observed increase in PPI use. In this study we describe the change in incident and prevalent PPI use over time and the indication for prescription.

Aims & Methods

Nationwide data were retrieved from the Norwegian Prescription Database (NorPD) and consisted of information about dispensed prescription drugs. The study population consisted of all adults with at least one PPI prescription during the study period from 2009 to 2022. PPIs were defined by their ATC codes A02BC01 – C05 in addition to M01AE52, which is an esomeprazole and naproxen combination product. Prevalent PPI use was defined as the period covered by the defined daily doses (DDD) in each prescription. The indications for prescription were defined by ICPC or ICD-10 codes depending on whether PPI was prescribed in primary care or secondary health care. National data from the Norwegian Patient Registry (NPR) on all upper endoscopies performed during the study period were combined with NorPD data and it was assessed whether incident PPI users, defined as no PPI dispensal for two years, had undergone an upper endoscopy 180 days before or after incident PPI use.

Results

The use of PPI increased from 58.1 mill DDD in 2009 to 166.9 mill DDD in 2022, i.e. 15700 DDD/1000 and 38700 DDD/1000 persons. The absolute increase in DDDs was driven by a 3.5-fold increase in esomeprazole and a 5-fold increase in the use of pantoprazole.
The prevalence of PPI use increased from 3.5% in 2009 to 9.9% in 2022. The incidence of PPI use increased from 2.85% in 2011 to 5.42% in 2022.
In 2009 the dominant indications in primary and secondary health care, respectively, were esophageal disease and GERD (72.5% and 10.7% of DDDs), gastric ulcer (3.3% and 0.46% of DDDs), duodenal ulcer (0.86% and 0.21% of DDDs), while prescriptions with no reimbursement diagnosis constituted 10.2% of DDDs. In 2022 the dominant indications were esophageal disease and GERD (57.6% and 4.7% of DDDs), musculoskeletal disorders and pain (7.1% and 0.39% of DDDs and in combination with naproxen), prophylaxis against gastroduodenal ulcer (4.8% and 0.95% DDDs), while prescriptions with no reimbursement diagnosis constituted 5.2% of the DDDs.
There were 2.27 mill cases of incident PPI use in the study period and the proportion of PPI users that underwent upper endoscopy around treatment start decreased from 25.3% in 2009 to 11.1% in 2022. In patients with esophageal disease or GERD combined the proportion examined by upper endoscopy fell from 41.4% to 27.1%, while in patients without a reimbursement diagnosis the proportion fell from 19.2% to 6.9%.

Conclusion

In this nationwide study a 2.8-fold increase in prevalent PPI use was observed during the 14-year study period. This was caused by an absolute increase in PPI use against esophageal disease and GERD as well as prophylaxis in patients given ulcerogenic comedication. The proportion of incident PPI use investigated by upper endoscopy was halved.