Introduction

Hiatal hernia (HH) is a common finding in endoscopic examinations that can cause significant symptoms, depending on its severity. The Hill classification assesses the degree of HH (type II to IV) by considering the width of the cardia and the hiatus on visual inspection during gastroscopy.

Aims & Methods

Our goal was to train a deep learning (DL) model that determines the Hill classification using a novel active learning (AL) pipeline. A total of 21,970 gastroscopic images representing 14,885 examinations from two endoscopy centers were retrospectively identified as the training dataset. A novel AL pipeline was developed to train the DL model. For comparison reasons, a second model was trained with randomly selected images from the same training dataset. An external, publicly available collection of HH images was annotated using the Hill classification and used as test data. Outcomes are the ability of the models to diagnose and classify HH and the time spent by the expert for annotation. The proposed AL pipeline is provided as Open-Source.

Results

The AL-based model was generated in eight consecutive steps, covering about 10% of the unlabeled training data. The model achieved mean accuracy, sensitivity, specificity, and F1-score of 0.878, 0.692, 0.896, and 0.67 respectively, when classifying the four different types of Hill. In diagnosing the existence of a HH (type I vs II-IV), the model achieved 0.828, 0.749, 0.902, 0.808 for the same metrics. The median annotation time per image was 3.62s (Q1-Q3; 3.14-4.69). Obtaining a model via the random image selection that performs similarly, required at least 30% more annotations and thus expert time commitment.

Conclusion

In this work we present a novel AL pipeline, enabling examiners to develop new models for gastrointestinal endoscopy without requiring programming skills. Using the proposed pipeline resulted in a well performing model in less time spent by the expert annotator, compared to traditional model training.

Disclosure

The authors have no conflicts of interest to disclose.

Introduction

Helicobacter pylori (H. pylori) infection has a high prevalence (44.8%) in China and is an important risk factor of gastrointestinal diseases including gastric cancer. Bismuth quadruple therapy (BQT; bismuth + acid suppressant + 2 antibiotics [ABs]) is the currently recommended first-line regimen for H. pylori in China. Increasing AB resistance poses a vital challenge and remarkably reduces the eradication rate (ER) from 95% to 80% globally and 89% to 78% in China. Real-world ER analysis assessed only quadruple therapy in a few single centers and did not focus on different antibiotic combinations and other different regimens.

Aims & Methods

This study was designed to evaluate the diagnosis and treatment pattern of H. pylori infection and the effectiveness of eradication therapy in real-world settings in China. In this retrospective, multicenter study (NCT05073367), de-identified patient data were extracted from the electronic medical records database of 3 hospitals between January 1, 2019, and March 31, 2021. Patients aged ≥18 years with a record of H. pylori infection diagnosis were included. Here we presented the eradication rate of different treatment regimens and the eradication rate of different years with different treatment regimens.

Results

A total of 1426 patients received ET with efficacy evaluation duration＞4 weeks after the eradication therapy and the total eradication rate was 72.09% (n=1028). Most patients (80.36%; n=1146) received standard BQT with an ER of 76.70% (n=879). 158 patients (11.08%) received dual therapy (ER=56.96%; n=90) and 122 patients (8.56%) received triple therapy (ER=48.36%; n=59). Compared with triple and dual therapies, BQT was the predominant regimen in all the years with an ER of 77.86%, 67.64%, and 82.78% in 2019, 2020, and 2021, respectively. The ER of dual therapy was 50% in 2020 and 61.22% in 2021. The triple therapy ER showed a decreasing trend with 78.57% (n=11), 46.25% (n=37), 39.29% (n=11) from 2019 to 2021. Among the BQT regimens, amoxicillin plus furazolidone based regimens showed a higher ER (87.44%; n=181), while the ER of amoxicillin plus levofloxacin, amoxicillin plus clarithromycin based BQT was 77.94% (n=159) and 76.07% (n=391), respectively. Amoxicillin plus furazolidone based BQT showed a higher ER of 87.30%, 83.02%, and 90.11% in 2019, 2020, and 2021 respectively (Table 1).
Table 1. Eradication rate of H. pylori positive patients based on the type of eradication therapy

Total (N=1426) → /Treatment regimens ↓	ER-success n (%)b	Year 2019 Success n (%)b	Year 2020 Success n (%) b	Year 2021 Success n (%)b
Total	1028 (72.09)	454 (77.87)	253 (60.96)	321 (75.00)
Bismuth Quadruple Therapy Amoxicillin and Clarithromycin Amoxicillin and Furazolidone Amoxicillin and Levofloxacin Amoxicillin and Metronidazole Other Bismuth Quadruple Therapy	879 (76.70) 391 (76.07) 181 (87.44) 159 (77.94) 2 (50.00) 146 (67.28)	443 (77.86) 169 (78.24) 55 (87.30) 126 (79.25) 2 (50.00) 91 (71.65)	186 (67.64) 106 (67.95) 44 (83.02) 10 (55.56) 0 (0.00) 26 (54.17)	250 (82.78) 116 (81.69) 82 (90.11) 23 (85.19) 0 (0.00) 29 (69.05)
Triple therapyc Dual therapyc	59 (48.36) 90 (56.96)	11 (78.57) 0 (0.00)	37 (46.25) 30 (50.00)	11 (39.29) 60 (61.22)

Abbreviations: N, total number; n, number in respective category.
^a% = The total usage count of BQT/Triple therapy/Dual therapy eradication therapy/the total usage count of all standard eradication therapies taken by eligible participants. Of BQT, the total usage count of different BQT/the total usage count of all BQT.
^b% = The number of participants with a negative efficacy evaluation result/the number of participants receiving certain eradication therapy.
^cConsidering the table size, outcomes of different treatment regimens under dual and triple therapy were not included in the table.

Conclusion

BQT-based regimens were predominantly prescribed for H. pylori management and the current H. pylori treatment regimens have a suboptimal eradication rate in the real-world settings.

Disclosure

The study was funded by Takeda China. Wensheng Pan, Yan Zhao, and Hongwei Xu have no conflicts of interest. Pengfei Li, Fang Zhou, and Li Xie are employees of Takeda, and they hold Takeda stock options. Medical writing for the development of this abstract was provided by Swathirajan CR, PhD, and Kusuma Kumari G, PhD, of Indegene Private Limited, and funded by Takeda China. Authors retained full control of the abstract content.

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.

Introduction

It is unclear whether the insertion of an axis-orienting double-pigtail plastic stent (DPS) through biliary lumen-apposing metal stents (LAMS) in EUS-guided choledochoduodenostomy (CDS) improves the stent patency.

Aims & Methods

The aim is to determine whether this technical variant offers a clinical benefit in EUS-guided biliary drainage (CDS-type) for the management of distal malignant biliary obstruction. This is a multicentre, open-label, randomised controlled trial with two parallel groups. The primary endpoint was the rate of recurrent biliary obstruction (RBO), as a stent dysfunction parameter, detected during follow-up. Secondary endpoints: technical and clinical success (reduction in bilirubin >50% within 14days), adverse events, and others.

Results

Between November-2020 and October-2022, 123 patients (pancreatic cancer 85%, palliative status 80%) were screened and 84 with malignant biliary obstruction, and underwent EUS-CDS (rescue after failed ERCP, 62%), were randomised: 44 patients in LAMS group and 40 in LAMS-DPS group. The rate of RBO (29.5 vs 10%; OR 0.26 [IC95% 0.07–0.83],p=0.04) was lower, but with a longer procedure time (30 vs 20-min, p=0.02), in LAMS-DPS-group. Furthermore, less biliary reinterventions (12.5 vs 20.5%, p=0.38), longer time-to-RBO (155.5 vs 51.5 days, p=0.10), and shorter hospital stay (6 vs. 8.5,p=0.06) were encountered in LAMS-DPS group. No differences were found between technical (97 vs. 88%), clinical success (92 vs. 88.8%) and AEs (22.5 vs.11.4%). NCT04595058 ClinicalTrials.gov

Table1: Outcomes (RBO, recurrent biliary obstruction; BRI, biliary reinterventions).

	N – 84	LAMS (N-44)	LAMS-Pigtail (N-40)	OR	p
RBO, n (%)	17 (20.2)	13 (29.5)	4 (10)	0.06(0.07-0.83)	0.04
BRI, n (%)	14 (16.7)	9 (20.5)	5 (12.5)	0.98(0.67-1.98)	0.38
Technical success,%	78 (92.9)	39 (88.6)	39 (97.5)	-	0.20
Clinical Success,%	75 (90.5)	39 (88.6)	37 (92.5)	-	0.71
Hospital stay, days	5.1(3-15.5)	8.5 (4.25-15.5)	6 (3-10)	-	0.06
Adverse Events, n	14 (16.1)	5 (11.4)	9 (22.5)	-	0.243
Related-AEs, n	10 (13.1)	3 (6.8)	8 (20.0)	-	0.11

Conclusion

This trial confirms that CDS with LAMS is an effective technique. The technical strategy of placing a pigtail within the LAMS is associated with a lower risk of RBO, and a non-significant trend of shorter hospital stay.

References

1-Garcia-Sumalla, A., Loras, C., Sanchiz, V. et al. Multicenter study of lumen-apposing metal stents with or without pigtail in endoscopic ultrasound-guided biliary drainage for malignant obstruction—BAMPI TRIAL: an open-label, randomized controlled trial protocol. Trials 2022; 23:181
2-Gornals JB, Consiglieri CF, Bergamino MA. Double pigtail for preventing ascending cholangitis after endoscopic ultrasonography-guided choledochoduodenostomy with lumen-apposing metal stent. Dig Endosc. 2016;28:100.
3-Garcia-Sumalla A, Loras C, Guarner-Argente C, et al. Is a coaxial plastic stent within a lumen-apposing metal stent useful for the management of distal malignant biliary obstruction? Surg Endosc. 2021;35:4873 –81

Disclosure

- A Garcia-Sumalla is a PhD student at the Faculty of Medicine and Health Sciences, University of Barcelona, and this paper is part of his doctoral project.
- Joan B Gornals acts as a PhD Director; is a consultant for Boston Scientific and has received a research grant from this company.
- Manuel Pérez-Miranda is a consultant and speaker for Medtronic, Olympus, Taewoong, and M.I.Tech.
- Enrique Vazquez-Sequeiros is a consultant for Boston Scientific.
Jose Ramon Aparicio is a consultant for Boston Scientific

Introduction

Eosinophilic esophagitis (EoE) is a Th2-related disease characterized by dysphagia and food impaction. EoE has been associated with several other atopic disorders, supporting the knowledge that it may represent a late manifestation of the so-called “atopic march”. However; in everyday clinical practice, allergic comorbidities are rarely objectivized by means of specialist consultations and often rely on patients’ self-reporting. This bears the risk of not fully recognizing the burden of Th2-related pathology, since EoE patients may outgrow some of the allergic diseases presenting during childhood; or, conversely, they could underestimate the presence and severity of Th2-diseases. To this aim, a multidisciplinary task-force involving multiple specialists was established at our university hospital, in order to systematically investigate newly referred EoE patients.

Aims & Methods

This is a cross-sectional observational study, involving consecutive EoE patients that were referred to our tertiary center from January 2022. We prospectively collected data about patients’ clinical history, specifically recording the presence of Th2-related comorbidities. Each patient underwent an esophagogastroduodenoscopy with differential esophageal biopsies. After reaching a conclusive diagnosis of EoE, patients were referred to dermatology, ear, nose and throat specialist (ENT) for rhinofibroscopy, immunologist (performing prick test, as necessary) and respiratory consultant for spirometry.

Results

40 EoE patients were included (34M, age 31±12 years), with a mean age of onset of 23±16 years. A clinical history of Th2-comorbidities was reported by 90% of the overall population with rhinitis being the most prevalent comorbidity (77.5%), while no patient reported Chronic Rhinosinusitis with Nasal Polyps (CRwNP). Asthma, food allergy and atopic dermatitis (AD) were reported in 15 (37.5%), 14 (35%) and 9 (22.5%) patients, respectively. Following the consultations, the presence of asthma, food allergy and AD did not significantly differ (37.5 vs 30%, 35 vs 45% and 22.5 vs 20%), since only 3 patients reporting a history of asthma did not confirm the diagnosis at spirometry and one patient with a history of AD had dermographic urticaria. On the contrary, following ENT consultation, 6 patients with rhinitis received the diagnosis of CRwNP (0 vs 15%, p=0.01). Overall, nearly 60% of patients had two comorbid Th2 disorders besides EoE and 25% of the whole population of EoE patients had 3 or more.

Conclusion

Our results clearly support the need for a multidisciplinary team approach to investigate the burden of Th2-related pathology in EoE patients. In our hands, the prevalence of Th2-related comorbidities was as high as 97.5% of EoE patients and up to 63% of our population had 2 or more allergic disorders. Furthermore, CRwNP is frequently under-reported and properly diagnosed only following rhinofibroscopy. This is further from being irrelevant when managing EoE patients. Indeed, it may guide the most appropriate choice of therapy by targeting multiple atopic manifestations at the same time, since many Th2-related diseases share common pathophysiological mechanisms and treatment.