Introduction

Helicobacter pylori (H. pylori) remains a significant global pathogen, implicated in chronic gastritis, peptic ulcer disease, and gastric cancer. Over the past two decades, escalating resistance to key antibiotics—particularly clarithromycin, levofloxacin, and metronidazole—has reduced the effectiveness of standard triple therapies, with eradication rates falling below 70%. Refractory H. pylori infection, defined in this study as persistent infection after three or more failed eradication regimens, presents a growing therapeutic challenge. The absence of standardised rescue protocols and limited access to antibiotic susceptibility testing in many regions further complicates treatment. Innovative empirical strategies, especially those using agents with low resistance profiles, are urgently needed.

Aims & Methods

This real-world, prospective observational study aimed to evaluate the efficacy of a Modified Concomitant Therapy (MCT) regimen for the eradication of refractory H. pylori. Adults aged ≥18 years with confirmed H. pylori infection persisting after at least three previous treatment attempts were recruited from a gastroenterology centre in Bogotá, Colombia, between January and November 2023.

The MCT protocol included:

• Esomeprazole 40 mg, twice daily (before breakfast and dinner)
• Furazolidone 100 mg, every 8 hours
• Amoxicillin 875 mg every 8 hours (in patients <70 kg) or 1 g every 8 hours (in ≥70 kg)
• Tetracycline 500 mg, every 6 hours

Patients were counselled about the therapeutic difficulty and potential adverse effects. The treatment duration was 14 days. Eradication was assessed 6–8 weeks post-therapy using histological evaluation with haematoxylin-eosin and Giemsa staining. This choice was based on prior discordance between breath test results (often negative) and biopsy (positive). Effectiveness was analysed both by modified intention-to-treat (mITT) and per-protocol (PP) methods.

Results

A total of 30 patients were enrolled (mean age: 45 ± 6 years; range: 28–63).

• mITT eradication rate: 27/30 (90%, 95% CI: 72.3–97.4)
• PP eradication rate: 25/27 (92.5%, 95% CI: 76.3–97.9)

Adverse events were reported in 8 patients:

• Nausea (30%)
• Headache (33%)
• Diarrhoea (16%)
• Constipation (10%)

Three patients discontinued treatment prematurely between days 10 and 12. No severe adverse events or hospitalisations occurred. The major limiting factor for broader enrolment was intermittent availability of tetracycline.

Conclusion

This study demonstrates that Modified Concomitant Therapy represents a promising and effective option for the eradication of refractory H. pylori infection in real-world settings. With an eradication rate exceeding 90% and manageable adverse effects, MCT using furazolidone, amoxicillin, tetracycline, and high-dose PPI constitutes a rational empirical rescue strategy in regions where antibiotic resistance testing is unavailable and first-line therapies have failed. Further multicentre studies with larger cohorts are warranted to confirm these findings and assess long-term outcomes. The development of accessible tetracycline formulations would enhance implementation.

References

1. Malfertheiner P, Megraud F, Rokkas T, Gisbert JP, Liou JM, Schulz C, et al. Management of Helicobacter pylori infection: the Maastricht VI/Florence consensus report. Gut. 2022 Jan;71(1):172–95. doi:10.1136/gutjnl-2021-325210.
2. Graham DY, Lee YC, Wu MS. Rational Helicobacter pylori therapy: evidence-based medicine rather than medicine-based evidence. Clin Gastroenterol Hepatol. 2014 Feb;12(2):177–86.e3. doi:10.1016/j.cgh.2013.06.020.
3. Liou JM, Chen CC, Chang CY, Chen MJ, Fang YJ, Lee JY, et al. Sequential versus triple therapy for the first-line treatment of Helicobacter pylori: a multicentre, open-label, randomised trial. Lancet. 2013 Feb 16;381(9862):205–13. doi:10.1016/S0140-6736(12)61455-0.

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

Hepatitis E virus (HEV) infection in Europe is predominantly due to zoonotic genotype 3, transmitted via undercooked pork, game or shellfish (1,2). In the Helsinki and Uusimaa Hospital District (HUS), 70 laboratory-confirmed cases occurred from 2020–2024, with a pronounced peak in early 2024 (3). Seroprevalence in high-income countries ranges from ~6 % to > 50 %, increasing with age and swine exposure (1,2). While most infections are asymptomatic or mild, patients with underlying liver diseases may have more severe outcomes. Diagnosis relies on anti-HEV IgM/IgG serology and PCR detection of viral RNA (4).

Aims & Methods

Objective of this study is to investigate the epidemiology of hepatitis E virus (HEV), its clinical manifestations, and factors associated with hospitalization in the Helsinki University Hospital (HUS) area between 2020 and 2024. We conducted a retrospective registry study including all patients diagnosed with hepatitis E in the HUS area from January 2020 to December 2024. Data were collected from the electronic health record system, the laboratory database, and the shared contact-tracing software of the HUS Epidemiology Unit and Uusimaa welfare regions. Variables analyzed comprised demographic data, symptoms at presentation, key laboratory parameters (ALT, bilirubin, C-reactive protein), probable sources of infection, and details of hospitalization episodes.

Results

Study population: 70 patients (median age 58 years [IQR 45–67]; 58.6 % male).
Clinical manifestations: 92.2 % were symptomatic. The most frequent symptoms were fatigue (55.9 %), abdominal pain (47.5 %), nausea (45.8 %), and jaundice (42.6 %).
Laboratory findings: Median peak ALT was 1 153 U/L (IQR 544–1 538); median peak bilirubin 39 μmol/L (IQR 17–79); median peak CRP 22 mg/L (IQR 11–32).
Genotypes: Of 19 genotyped cases, 3c (21.1 %), 3e (21.1 %), and 3f (57.9 %), with genotype 3f predominant.
Infection sources: Cold-smoked sausages (e.g., mettwurst) were implicated in most domestic cases (69.6 % of identified sources), especially during the early 2024 outbreak. Other identified sources were unspecified meat products (6.5 %), berries (6.5 %), contact with wild animals (e.g., hunting, 4.3 %), blood transfusion (4.3 %), pork meat (4.3%), and game meat (4.3%).
Hospitalization: 50.7 % required ≥1 night of inpatient care. Hospitalized patients were older, had higher ALT, bilirubin, and CRP values, and more comorbidities than outpatients.
Predictors of hospital stay: In a multivariable zero-inflated negative binomial model, higher peak CRP was independently associated with longer hospital stay (β = 0.02; p = 0.005).

Conclusion

The early-2024 surge of HEV cases in the HUS area represents an internationally rare, large genotype 3 outbreak. Cold-smoked meat products were identified as the principal transmission route, although infections linked to blood transfusions, consumption of raw berries, and wildlife contact also occurred. Cases were disproportionately concentrated in men over 50 years of age. Among hospitalized patients, peak CRP emerged as the strongest predictor of inpatient care, and both mortality and incidence of hepatic insufficiency were relatively high given high sanitation standards in Finland. Further multicenter, inter-regional studies are needed to establish statistically robust risk factors for severe outcomes and to guide clinical and public health interventions.

References

1. Luo Q, Chen J, Zhang Y, Xu W, Liu Y, Xie C, ym. Viral hepatitis E: Clinical manifestations, treatment, and prevention. Liver Res. maaliskuuta 2024;8(1):11–21.
2. Hartl J, Otto B, Madden RG, Webb G, Woolson KL, Kriston L, ym. Hepatitis E Seroprevalence in Europe: A Meta-Analysis. Viruses. 6. elokuuta 2016;8(8):211.
3. THL. Terveyden ja hyvinvoinnin laitos. 2024 [referenced: 13. lokakuuta 2024]. Hepatiitti E-tapausten esiintyvyys Suomessa – THL. Available: https://thl.fi/aiheet/infektiotaudit-ja-rokotukset/taudit-ja-torjunta/taudit-ja-taudinaiheuttajat-a-o/hepatiitti-e/hepatiitti-e-tapausten-esiintyvyys-suomessa
4. Dalton HR, Kamar N, Baylis SA, Moradpour D, Wedemeyer H, Negro F. EASL Clinical Practice Guidelines on hepatitis E virus infection. J Hepatol. kesäkuuta 2018;68(6):1256–71.

Introduction

Acute biliary pancreatitis (ABP) has been shown to be associated with increasing incidence and health-care costs, and possibly higher mortality than other etiologies. Despite the existence of various scoring systems, early and accurate risk stratification remains difficult. Due to heterogeneity of populations, focusing on one etiology might reveal important insights concerning predictors of outcome.

Aims & Methods

We conducted a retrospective, multicenter cohort study including all patients admitted with ABP between 2018 and 2021 at two hospitals. Epidemiological, clinical, and outcome data were analyzed. The main clinical outcome of interest was a hierarchical composite endpoint of five mutually exclusive clinical states: (i) death (90-day all-cause mortality), (ii) severe AP and/or admission to the intensive care unit (ICU), (iii) endoscopic, interventional radiological, or surgical interventions, (iv) moderately-severe AP, (v) mild AP. Univariable logistic regression identified parameters associated with worse outcomes, which were then tested in multivariable models. Emphasis was placed on early availability and clinical practicality of predictors. We aimed to stratify patients into outcome trajectories reflecting both health impact and healthcare resource utilization.

Results

Out of 569 total acute pancreatitis cases, 217 (38.1%) patients had ABP (mean age 65.9 ±17.4 years; median length of stay (LOS) 7 days, IQR 4;11) Mild, moderately-severe, and severe disease occurred in 62.2%, 30.0%, and 7.8% of patients. All-cause 90-day mortality was 2.3%. Several parameters were significantly (p<0.05) associated with worse outcomes, including BISAP and the Charlson comorbidity index (CCI) (p<0.001). Individually, BISAP and CCI classified patients reasonably, however, wide prognostic uncertainty persisted. When combining BISAP and CCI (BISAP-C), 5 discrete risk groups were identified, ranging from low (group 1, BISAP 0-2 & CCI 0-2) to very-high risk (group 5, BISAP 3-5 & CCI ≥6) (see Table 1). The prevalence of severe outcomes (i–iii) increased across these strata: 2.4% (Group 1), 9.5% (Group 2), 27.3% (Group 3), 60% (Group 4), and 62.5% (Group 5), with LOS also significantly longer in higher-risk groups (p<0.001). Mortality was 50% in group 5, while, importantly, 97.6% of patients in group 1 experienced mild-to-moderate AP without ICU admission, persistent organ dysfunction, surgical or endoscopic interventions, and no fatality, supporting potential early discharge. This also occurred in 90.5% of group 2. Notably, Groups 1 and 2 together comprised nearly 80% of the cohort.

Conclusion

Comorbidity seems to play a major role concerning worse outcomes in ABP. The combination of CCI and BISAP (BISAP-C), both comprised of early-on and easily available parameters, offers improved early prognostic discrimination and may provide tailored, individualized management and healthcare resource utilization.

Introduction

Propofol (PPF) is a short-acting, highly lipophilic intravenous agent with sedative, hypnotic, antiemetic, and amnestic properties. Acting through GABA receptor agonism and NMDA antagonism, it ensures rapid onset (30–45 seconds) and swift recovery, making it ideal for gastrointestinal endoscopic procedures. Since 1995, the American Society of Anesthesiologists has supported the use of non-anaesthesiologist providers for sedation in endoscopy. Countries including Colombia have adopted this approach, especially given the limited availability of anaesthesiologists. In the United States, fewer than 20% of colonoscopy sedations are delivered by anaesthesiologists. Recent studies report comparable safety profiles for trained non-anaesthesiologist and anaesthesiologist-administered sedation, with reduced cardiovascular complications and lower healthcare costs. However, Latin American real-world data on this model remain scarce.

Aims & Methods

This prospective, analytical prevalence study assessed the safety and effectiveness of propofol sedation administered by a general physician with specific training in sedation, airway management, and intensive care, within an ambulatory endoscopy unit. From March 2023 to April 2024, adult patients (≥18 years) undergoing colonoscopy at the Centro de Gastroenterología y Endoscopia in Bogotá were included. The physician administered age-tailored propofol bolus and maintenance doses according to clinical guidelines and procedure duration. Exclusion criteria included ASA IV status or contraindications to propofol. Sedation regimens were as follows:

• <40 years: 180 mg IV bolus; 60 mg maintenance every 5 min
• 41–70 years: 160 mg IV bolus; 50 mg maintenance every 5 min
• ≥71 years: 150 mg IV bolus; 30 mg maintenance every 5 min

Results

A total of 2,032 patients were enrolled; mean age 64 years (95% CI: 62.8–65.1), 60% female. The mean BMI was 27 (95% CI: 25.8–27.1). Colonoscopy indications included screening (35%), diagnostic evaluation (40%), surveillance (20%), and therapeutic intervention (5%), including 101 patients undergoing polypectomy. Comorbidity prevalence was notable: cardiovascular (30%), gastrointestinal (30%), respiratory (15%), neurological (5%), allergic (3%), and haematological (3%).
ASA risk classification revealed:

• ASA I: 14% (n=284)
• ASA II: 60% (n=1,219)
• ASA III: 26% (n=528)

Conclusion

This real-world study confirms that propofol sedation administered by non-anaesthesiologist physicians with critical care training is both safe and effective for the vast majority of patients undergoing colonoscopy in ambulatory settings. These findings support a task-sharing model that maximises resource efficiency while maintaining patient safety. In health systems with limited anaesthesiologist availability, this approach allows specialists to focus on higher-risk ASA IV patients in tertiary-level settings. Widespread adoption of this model, with appropriate training, could reduce costs, increase procedural throughput, and improve access to high-quality endoscopic care in Latin America and similar settings.

References

• Sato M, Horiuchi A, Tamaki M, et al. Safety and effectiveness of nurse-administered propofol sedation in outpatients undergoing gastrointestinal endoscopy. Clin Gastroenterol Hepatol. 2019;17(6):1098–1104.e1. doi:10.1016/j.cgh.2018.06.025.
• Ferreira AO, Torres J, Barjas E, et al. Non-anesthesiologist administration of propofol sedation for colonoscopy is safe in low-risk patients: results of a noninferiority randomized controlled trial. Endoscopy. 2016;48(8):747–753. doi:10.1055/s-0042-105560.
• Lucendo AJ, Olveira A, Friginal-Ruiz AB, et al. Nonanesthesiologist-administered propofol sedation for colonoscopy is safe and effective: a prospective Spanish study over 1000 consecutive exams. Eur J Gastroenterol Hepatol. 2012;24(7):787–792. doi:10.1097/MEG.0b013e328353fcbc.