Introduction

Helicobacter pylori (H. pylori) infection is a well-established risk factor for gastric cancer. While high-incidence countries promote population-based test-and-treat strategies, Germany—classified as an intermediate-risk country—follows a more targeted approach. According to the latest German S3 guidelines, H.pylori eradication is strongly recommend in specific high-risk groups, including first-degree relatives of gastric cancer patients and individuals who have undergone surgical or endoscopic resection of gastric cancer. However, real-world data on how these recommendations are implemented in clinical practice remain limited. Additionally, data on the use and effectiveness of different first-line eradication regimens in Germany are sparse.

Aims & Methods

We conducted a retrospective analysis of patients who received first-line empirical H. pylori eradication therapy across five German university-based centers participating in the European Registry on H. pylori Management (Hp-EuReg). Three centers contributed the majority of cases. Demographic and clinical data were extracted from databases. Data were collected in AEG-REDCap from June 2013 to January 2025. Indications were categorized by symptom profile, endoscopic findings, and cancer risk. A descriptive analysis was performed. Eradication rates were compared between treatment regimens and durations using the χ² test. A particular focus was placed on evaluating how the recommendations of the German S3 guidelines regarding gastric cancer prevention were implemented in clinical practice.

Results

Of the 448 patients (53% male, median age 55) ncluded, the most common indications were non-investigated dyspepsia (33%) and dyspepsia with normal endoscopy (30%). Peptic ulcer disease was reported in 18%: duodenal ulcer (5%) and gastric ulcer (13%). Five percent underwent eradication for gastric cancer prevention; these included patients with preneoplastic lesions (0.4%), prior gastric cancer resection (0.9%), first-degree relatives of gastric cancer patients (2.0%), and individuals undergoing screening (1.3%). Other indications included unexplained iron deficiency anemia (4.0%), vitamin B12 deficiency (0.7%), and MALT lymphoma (0.2%). The most frequent first-line therapies were triple therapy with amoxicillin and clarithromycin (54%) and a three-in-one single-capsule containing metronidazole, tetracycline, and bismuth (41%). Therapy commonly lasted 7 (19%) or 10 days (72%). No difference in eradication rates between the two regimens was observed when given for 10 days (97.8% vs. 97.0%, respectively).

Conclusion

In this multicenter German cohort from dedicated H. pylori centers, most eradication therapies were prescribed for dyspeptic symptoms. Notably, a significant proportion of treatments aimed at gastric cancer prevention, aligning with the approach outlined in the current German S3 guidelines. Both recommended first-line therapies—triple therapy with amoxicillin and clarithromycin, and the three-in-one single-capsule bismuth-based quadruple therapy—were widely used and achieved similarly high eradication rates when administered for 10 days. These findings underline the importance of implementing guideline-based indications in intermediate-risk countries like Germany, where targeted eradication in high-risk individuals remains a cornerstone of gastric cancer prevention.

Introduction

The risk of developing gastric carcinoma is closely associated with the severity and extent of premalignant conditions, namely gastric atrophy and intestinal metaplasia. The most recent guidelines for screening and surveillance recommend collecting biopsies from at least two topographic sites (two from the antrum/incisura and two from the corpus, placed in separate and clearly labelled vials), considering incisura angularis biopsy as optional.

Aims & Methods

This study aims to assess the relevance of performing a random biopsy of the incisura angularis for the diagnosing and staging premalignant gastric conditions. We conducted a retrospective cohort study between November/2023 and January/2025, including patients undergoing screening upper endoscopy, endoscopy for dyspeptic symptoms or chronic gastritis monitoring. Biopsies were collected according to the RE.GA.IN protocol, with an additional biopsy from the incisura angularis placed in a third vial. Endoscopic and histological findings were collected and analyzed.

Results

A total of 192 patients underwent high-quality endoscopy, including virtual chromoendoscopy with Blue Light Imaging (57.3% female; mean age 59.6±15.2 years). Most procedures (56.3%) were performed without sedation, followed by anesthesia (23.4%) and conscious sedation (20.3%), with overall good (76.6%) and reasonable (16.7%) tolerance. High risk OLGA/OLGIM stages (III and IV) were identified in 2.1% and 7.8% of patients, respectively (OLGA: stage I-29.7%, II-5.7%, III - 2.1%; OLGIM: stage I - 18.8%, II - 18.8%, III - 7.3%, IV - 0.5%). The addition of a random incisura angularis biopsy altered the overall OLGA score in 16.1% of patients and the OLGIM score in 15.6%, but it contributed to an upgrade to high-risk stages in only three patients (1.6%). Specifically, in two patients, the OLGIM stage increased from 0 to III, and in one patient, the OLGA stage increased from 0 to III.

Conclusion

Our findings suggest that while the incisura angularis biopsy provides some additional diagnostic value, its impact on identifying high-risk patients and influencing the recommended endoscopic surveillance intervals is limited.

References

1. Rugge M, Genta RM, Malfertheiner P, et al. RE.GA.IN.: the Real-world Gastritis Initiative-updating the updates. Gut. 2024;73(3):407-441. Published 2024 Feb 23. doi:10.1136/gutjnl-2023-331164
2. Dinis-Ribeiro M, Libânio D, Uchima H, et al. Management of epithelial precancerous conditions and early neoplasia of the stomach (MAPS III): European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter and Microbiota Study Group (EHMSG) and European Society of Pathology (ESP) Guideline update 2025. Endoscopy. 2025;57(5):504-554. doi:10.1055/a-2529-5025
3. Ferrari F, Ogata DC, Mello CAL. Role of incisura angularis biopsy in gastritis staging and risk assessment of gastric cancer. Arq Gastroenterol. 2023;60(4):478-489. doi:10.1590/S0004-2803.23042023-120

Introduction

Endoscopic drainage is standard of care in malignant biliary obstruction (MBO).

Aims & Methods

The aim of this study was to investigate efficacy of biliary stenting in providing access to systemic chemotherapy. Patients with biliary obstruction (bilirubin >2.5 mg/dl) caused by unresectable biliary or pancreatic cancer were retrospectively analyzed with respect to use of chemotherapy and survival. Laboratory data were analyzed at baseline, 7-10 and 28-35 days following biliary stenting.

Results

Patients with MBO (n=78) were allocated into one of three groups according to bilirubin level [mg/dl] 2.5 – 5.99 (group 1), 6.0 - 15.0 (group 2) and >15 (group 3). On first blood testing mean bilirubin declines from baseline in respective groups were: 1.19 (29.5%), 3.77 (38.5%) and 7.1 (27.3%), and on second measurement 1.61 (40%), 5.69 (58.2%) and 13.0 (50%). Chemotherapy was applied in 28 (35.8%) patients, less frequently in group 3 than in group 1 (31.2% vs 44.0%; p =0.07) and group 2 (vs 38.1%; p =0.06). Mean survival time was 4.8 ±2.8 months and was significantly shorter in group 3 as compared to group 2 (3.8 ±2.0 vs 6.2 ±3.9 months; p =0.02) and to group 1 (vs 5.4 ±2.7 months; p =0.03).

Conclusion

In two-thirds of patients with MBO endoscopic biliary drainage does not grant access to chemotherapy. Use of chemotherapy and survival time are significantly higher in patients with bilirubin level below 15 mg/dl as compared to those with greater bilirubinemia, but in patients with bilirubin level below 6 mg/dl the biliary drainage is minimally effective.

Disclosure

No.

Introduction

Common bile duct (CBD) stones are one of the most frequent indications for endoscopic retrograde cholangiopancreatography (ERCP). Endoscopic complete sphincterotomy (EST) followed by balloon or basket extraction is widely considered the gold standard technique for the treatment of CBD stones; being successful in more than 90% of cases with approximately 5% overall rate of adverse events [1]. Endoscopic papillary large balloon dilatation (EPLBD) is an effective technique in treating large common bile duct (CBD) stones. However, the efficacy and safety of EPLBD in the setting of periampullary diverticula (PAD) are prospectively lacking.

Aims & Methods

This study aimed to compare the effectiveness and short-term safety of EPLBD after limited sphincterotomy with those of EST for extracting large CBD stones in the setting of PAD prospectively. Forty-eight patients with large CBD stone(s) > 1 cm were recruited. All patients had a PAD. Before the procedure patients were evaluated by history taking, clinical examination full investigations including proper imaging studies. During the procedure, patients were randomized to either group I; patients treated with EPLBD after limited sphincterotomy, and group II; patients treated with EST. CBD clearance was defined as a single procedure (EPLBD vs EST), single session (no repeat ERCP), and non-assisted (no lithotripsy used) stone extraction. After the procedure patients were hospitalized with clinical, laboratory, and imaging assessment.

Results

Table 1: Univariate regression of the parameters affecting stone extraction

PAD: periampullary diverticulum			* significant as P value≤ 0.05
	Odds ratio	95% CI	P value​
The used technique	5.92	1.32 to 25.3	0.009∗
Stone (s) number	0.62	0.17 to 2.25	0.468
Stone (s) diameter (mm)	2.59	0.63 to 10.56	0.187
Type of PAD​	1.32	0.65 to 2.67	0.437

The overall stone extraction rate in the current study was only 77.3% (n=34). The efficacy of stone extraction was significantly higher in the EPLBD (n= 21,87.5%) group compared to EST (n= 13, 54.17%) group (p = 0.011). The procedure-related adverse events were lower in the EPLBD group compared to the EST group. Pancreatitis was significantly higher in the EST (n=14, 58.33%) group than in the EPLBD (n=3, 12.5%) group (p= 0.001). There were no perforations or case fatalities in either group. The predictors of stone extraction were analyzed using univariate regression (Table 1), and it is noticeable that the used technique was the independent predictor of success in stone extraction (Odds Ratio: 5.92, 95% Confidence Interval: 1.38 to 25.30, p-value = 0.009).

Conclusion

The current practice guidelines of the ESGE and ASGE suggest that for large CBD stones, an EST followed by a large balloon dilatation is preferable to EST alone because combining dilatation with EST improves duct clearance and reduces the need for lithotripsy without adding risk. Our results among PAD patients seem to echo this: the EPLBD approach in comparison to EST yielded higher stone clearance on first attempt even without using lithotripsy by the study design. Hence, based on the current study these existing recommendations can be extrapolated to the PAD population based on our study which is one of the first randomized trials in the specific PAD subgroup.

References

1. Zippi M, Traversa G, Pica R, De Felici I, Cassieri C, Marzano C, et al. Efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) performed in patients with Periampullary duodenal diverticula (PAD). Clin Ter. 2014;165(4):e291-4.

Introduction

This study investigates the dynamic mechanisms by which Helicobacter pylori (Hp) eradication therapy influences gut microbiota and metabolome. Current rescue regimens, specifically high-dose dual therapy (HDDT) combining vonoprazan (VPZ) and amoxicillin, lack thorough exploration regarding their effects on gut microbiota and host metabolism. Additionally, the timing of probiotic intervention remains poorly understood.

Aims & Methods

Utilizing multi-omics approaches, this study aims to clarify how probiotics administered at different times influence gut microbial composition, metabolic profiles, and their interaction in patients undergoing Hp rescue therapy, thereby providing a theoretical foundation for enhancing Hp eradication strategies through microbial-metabolic modulation.
From January to December 2024, 120 patients undergoing Hp rescue therapy were randomized into four groups (A–D). Group A received VPZ 20 mg bid + amoxicillin 0.75 g qid for two weeks, followed by Bacillus subtilis dual-strain enteric-coated capsules (2 tablets tid) for two weeks. Group B received VPZ 20 mg bid + amoxicillin 0.75 g qid + Bacillus subtilis capsules (2 tablets tid) for two weeks. Group C was treated with VPZ 20 mg bid + amoxicillin 0.75 g tid for two weeks. Group D received Bacillus subtilis capsules (2 tablets tid) for two weeks, followed by VPZ 20 mg bid + amoxicillin 0.75 g qid for two weeks. Twenty-five Hp-negative individuals served as controls. Fecal samples were collected at baseline, 4 weeks, and 12 weeks post-treatment. Gut microbiota diversity and composition were analyzed through metagenomic sequencing; untargeted metabolomics was conducted using LC-MS; and small intestinal bacterial overgrowth was assessed via hydrogen-methane breath testing.

Results

1) No significant differences in gut microbiota alpha (Shannon index) or beta diversity (Bray-Curtis) were observed between H. pylori (Hp)-infected and uninfected groups (P=0.65). Hp-positive individuals exhibited elevated Collinsella aerofaciens and reduced Roseburia faecis and Agathobacter spp. (P<0.05). Metabolomic analysis identified 886 differentially abundant metabolites (P<0.05, VIP>1, FC≠1) enriched in 45 KEGG pathways, with key biomarkers including deoxyribose 5-phosphate and 4-vinylcyclohexene dioxide (P<0.01). The prevalence of SIBO was higher in patients with H. pylori infection than in those without infection (P<0.05). 2) Post-treatment alpha/beta diversity remained stable across groups A–D (P>0.05). Metabolic pathway profiles diverged: Group A emphasized phenylpropanoid biosynthesis; Group B showed cytochrome P450 drug metabolism; Group C featured sphingolipid metabolism and necroptosis; Group D upregulated cofactor/flavonoid biosynthesis. No significant SIBO changes occurred post-treatment in any group. 3) At week 4, beta diversity separation (P=0.009) was driven by Bacillota, Blautia, Ruminococcus sp., and Phocaeicola sp., with metabolites like Fahfa(3:0/24:1) linked to inflammation. By week 12, Groups B and C displayed distinct alpha (Sobs) and beta diversity (P=0.011), distinguished by Escherichia coli and Faecalibacterium prausnitzii. Group C exhibited upregulated anti-inflammatory metabolites (e.g., luteolin) and mucosal repair markers. 4) Multi-omics integration revealed early metabolic compensation at week 4 (Bifidobacterium-mediated amino acid/bile acid homeostasis) and late-stage recovery (week 12) marked by Pseudomonadota proliferation (E. coli) and Faecalibacterium grausatizii-associated sulfated steroids/phosphosphingolipids, supporting immune regulation and mucosal repair.

Conclusion

Probiotic-augmented HDDT has minimal impact on gut microbiota diversity and small intestinal bacterial overgrowth but significantly enhances the probiotic-microbiota-metabolite axis, particularly in sustaining anti-inflammatory metabolites and immune regulation.

Disclosure

The authors have no conflicts of interest to declare.

Introduction

Tissue acoustic properties, such as sound speed, attenuation, and impedance, are closely associated with its mechanical characteristics. Acoustic microscopy, which employs high-frequency ultrasound ranging from several tens of MHz to several GHz, enables the quantitative evaluation of these acoustic properties. Understanding the acoustic properties of biological tissues may offer new insights into disease pathology. Furthermore, because clinical ultrasound images depend on tissue acoustic properties, understanding them could improve the interpretation of echogenic patterns and contribute to developing new diagnostic approaches. Although acoustic microscopy has been applied to cardiovascular and cutaneous tissues in medical research, studies focusing on the liver, particularly hepatic tumours, remain limited.

Aims & Methods

This study aimed to quantify sound speed in hepatocellular carcinoma (HCC)—the most common primary liver tumour—and to examine its relationship with histopathological features. Histopathological classification followed World Health Organization criteria, including histological grade (well, moderately, and poorly differentiated) and histological growth pattern (trabecular, pseudoglandular, and solid). Tissue sound speed was measured using a scanning acoustic microscope (AMS-50SI; Honda Electronics Co., Ltd.) with an 80 MHz transducer. Regions of interest were identified on haematoxylin and eosin-stained slides. Serial 10 μm-thick sections were prepared from formalin-fixed, paraffin-embedded tissue blocks and rehydrated for measurement. Differences in sound speed among histological categories were compared, and statistical analysis was conducted to assess significance. A p-value of < 0.05 was considered significant. This study was approved by the institutional review board, and written informed consent was obtained.

Results

Tissue sound speed was measured at 66 sites from 51 patients. Histological grading identified 22 well, 41 moderately, and 3 poorly differentiated cases. Median sound speeds were 1584.0 m/s, 1595.9 m/s, and 1550.1 m/s, respectively. Poorly differentiated HCC showed significantly lower sound speed than the other grades (p = 0.021). Growth patterns included 50 trabecular, 10 pseudoglandular, and 6 solid cases, with median sound speeds of 1595.9 m/s, 1586.0 m/s, and 1563.6 m/s, respectively. The trabecular pattern tended to exhibit higher sound speed than the solid pattern (p = 0.063). Tissues with abundant fat or glycogen (n = 16) had significantly lower sound speeds than those without (p = 0.002). After excluding these cases, which could act as potential confounding factors, sound speed in poorly differentiated HCC remained significantly lower (p = 0.016), and higher values in the trabecular pattern persisted. Additionally, the pseudoglandular pattern showed greater variability in sound speed than the trabecular pattern.

Conclusion

Variations in acoustic properties among histological subtypes of HCC may contribute to developing novel quantitative assessments in ultrasound imaging and pathological diagnosis.

Disclosure

Kazuto Kobayashi, a co-author, has reported a relationship with Honda Electronics Co., Ltd. that includes: employment.

Introduction

Gastric cancer (GC) is the fifth most common malignancy worldwide and the fourth leading cause of cancer death. In Colombia, it ranks third in incidence and first in mortality, with a 5-year survival below 25% in advanced stages. Early detection relies on identifying premalignant lesions. OLGA and OLGIM histological staging systems enable risk stratification. While stages III–IV are known high-risk states, the role of stage II remains unclear. This study focuses on OLGA II to address this gap.

Aims & Methods

This systematic review and meta-analysis, registered on PROSPERO (CRD42024549931), adhered to PRISMA 2020 guidelines. The primary objective was to determine whether OLGA stage II confers a statistically significant risk of GC compared to stages 0–I. Secondary objectives included evaluating risks across all advanced stages (II–IV) and contrasting OLGA versus OLGIM staging.
We searched PubMed, EMBASE, and Cochrane up to 31 May 2024 using terms including "OLGA", "OLGIM", "gastric cancer", and "gastric intraepithelial neoplasia". Inclusion criteria covered cohort, case-control, and cross-sectional studies reporting GC incidence stratified by OLGA/OLGIM stage. Data extraction and quality assessment were performed independently by two reviewers using the Newcastle-Ottawa Scale, with evidence certainty assessed via GRADE. Meta-analytical synthesis used random-effects modelling, and heterogeneity was assessed with I² and Tau² statistics.

Results

Twenty-eight studies met inclusion criteria, comprising 13 cohort, 11 case-control, and 4 cross-sectional studies.

• OLGA II vs 0–I (Cross-sectional studies): A significantly increased GC risk was observed (Z = 3.14; P = 0.002; I² = 65%), suggesting OLGA II as an early but meaningful predictor of malignant transformation.
• OLGA II (Cohort studies): No statistically significant difference was found (P = 0.28; I² = 0%), though sample size was limited.
• OLGIM II: Demonstrated increased risk only in case-control settings (Z = 11.26; P < 0.00001), but not in cohort studies.

Findings for OLGA and OLGIM stages III–IV corroborated existing evidence of elevated risk. However, this is the first meta-analysis to demonstrate a potential oncogenic risk beginning at OLGA stage II, particularly evident in cross-sectional data.
Sensitivity analyses affirmed result consistency, and the certainty of evidence was rated moderate. Subgroup comparisons revealed that OLGA may outperform OLGIM in early risk discrimination.

Table 1. Summary of Gastric Cancer Risk According to OLGA and OLGIM Stages

Staging System	Stage	Study Design	Pooled Risk Estimate	95% CI	Heterogeneity (I²)	Significance (p-value)
OLGA	II vs 0–I	Cross-sectional	OR 2.34	1.36 – 4.02	65%	0.002
OLGA	II vs 0–I	Cohort	RR 1.20	0.85 – 1.69	0%	0.28
OLGA	III–IV vs 0–II	Case-control & Cohort	OR 4.87 / RR 3.12	–	88%	< 0.00001
OLGIM	II vs 0–I	Case-control	OR 1.95	1.52 – 2.50	0%	< 0.00001
OLGIM	II vs 0–I	Cohort	RR 1.10	0.85 – 1.42	0%	0.74
OLGIM	III–IV vs 0–II	Case-control & Cohort	OR 3.89 / RR 2.91	–	82%	< 0.00001

Abbreviations: OR = Odds Ratio; RR = Risk Ratio; CI = Confidence Interval

Conclusion

Our study highlights a pivotal finding: OLGA stage II—previously considered an intermediate state—emerges as a statistically significant risk factor for gastric cancer. These findings suggest that the progression to malignancy may begin earlier than currently recognised. Incorporating OLGA II into surveillance strategies could lead to improved early detection, especially in high-incidence countries. The data support a shift toward broader inclusion criteria for endoscopic follow-up and reinforce the clinical utility of histological staging in GC prevention frameworks.

References

• Yue H, Shan L, Bin L, Shi L. The OLGA and OLGIM staging systems are useful for assessing the gastric cancer risk: a systematic review and meta-analysis. Gastric Cancer. 2018;21(4):579–87. doi:10.1007/s10120-017-0779-4
• Rugge M, Genta RM, Zambon CF, et al. OLGA staging for gastritis: a tutorial. Dig Liver Dis. 2008;40(9):650–8. doi:10.1016/j.dld.2008.02.020
• Rugge M, Meggio A, Pennelli G, et al. Gastritis staging in the endoscopic follow-up for the secondary prevention of gastric cancer: a 5-year prospective study of 1755 patients. Gut. 2019;68(3):477–84. doi:10.1136/gutjnl-2017-315252
• Pimentel-Nunes P, Libânio D, Marcos-Pinto R, et al. Management of epithelial precancerous conditions and lesions in the stomach (MAPS II): European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter and Microbiota Study Group, European Society of Pathology, and Sociedade Portuguesa de Endoscopia Digestiva guidelines update 2019. Endoscopy. 2019;51(4):365–88. doi:10.1055/a-0859-0574
• Correa P. Human gastric carcinogenesis: a multistep and multifactorial process—First American Cancer Society Award Lecture on Cancer Epidemiology and Prevention. Cancer Res. 1992;52(24):6735–40.