Introduction

Prevalence of Helicobacter pylori (H. pylori) infection remains high. Despite the reported relatively low prevalence in Switzerland, the real burden is considered to be much higher, primarily due to the phenomenon of migration. Till now, there is scarce evidence regarding effectiveness of H. pylori eradication schemes in Switzerland.

Aims & Methods

Sub-study of the "European Registry on H. pylori Management" (Hp-EuReg), an international, multicenter, prospective non-interventional registry of the routine clinical practice. All infected adult patients were systematically registered at AEG-REDCap e-CRF from 2013 to December 2023. Swiss data were analysed for effectiveness on a modified intention-to-treat (mITT) basis.

Results

A total of 486 adult patients, diagnosed with H. pylori infection, were collected. Out of them, 428 (88.1%) were treatment-naïve patients. Two prescription regimes included more than 90% of the cases (triple with Clarithromycin and Amoxicillin in 49% and single-capsule bismuth quadruple in 42%). For the effectiveness analysis, 280 naïve patients were eligible, due to their availability of a confirmatory H. pylori eradication test. The overall effectiveness of 1^st line empirical therapy was 92% by mITT. The lowest effectiveness was recorded with triple therapy with amoxicillin and clarithromycin (28/34 cases, 82.4 % for seven days duration, and 86.9% overall (126/145). On the other hand, the highest effectiveness was reached with the single-capsule bismuth quadruple therapy (97.1%, 100/103). In respect to potency of gastric acid inhibition by proton pump inhibitors (PPI), the group with low-dose (i.e. 20 mg omeprazole equivalent twice daily) PPI yielded an overall eradication success of 90.8%, whereas for the standard-dose (i.e. omeprazole equivalent 40mg bid) and high-dose (i.e. omeprazole equivalent 80mg bid) PPI inhibition the rates increased up to 100% and 96.3%, respectively. Regarding safety, the eradications treatments were generally well tolerated, and serious adverse events were reported in 16 cases (5.7%). Mild adverse effects were rather uncommon and included dysgeusia (n=1), diarrhoea (n=6), nausea (n=6) and dyspepsia (n=3).

Conclusion

This first interim analysis of Swiss population as sub-study of the Hp-EuReg suggests that bismuth quadruple therapy prescribed as single-capsule represents a reliable option as first-line empirical therapy.

Introduction

Different pathophysiological mechanisms are thought to play a role in functional dyspepsia (FD) subgroups defined by Rome IV criteria. Studies are needed to determine whether Rome IV subgroups are linked to distinct pathophysiologies and treatment responses. This study aims to investigate the impact of Helicobacter pylori (H. pylori) infection in the pathogenesis of each FD subgroups, subdivided according to the Rome IV consensus, within a high H. pylori prevalence country, Turkey. The investigation centered on assessing the frequency of H. pylori and examining the impact of eradication therapy on alleviating symptoms, in each Rome IV subgroup.

Aims & Methods

Eradication treatment was applied to cases who were initially diagnosed with FD using the Rome IV criteria and subsequently found to have H. pylori gastritis through endoscopic biopsy. 8-12 weeks after treatment, H. pylori state was evaluated with fecal antigen test. Symptom responses were evaluated in each subgroup at 2, 6, and 12 months post-therapy using a Likert scale and statistically with SPSS version 23.0.

Results

The H. Pylori frequency was statistically more common in individuals with symptoms consistent with epigastric pain syndrome (EPS) (73.1% in EPS, 41% in postprandial distress syndrome (PDS), and 43.9% in overlapping subgroups (p< .001)). With eradication treatment of H. pylori-positive cases, all subgroups demonstrated a significant response and the response rates didn’t exhibit significant difference between subgroups (73.7% in total cases; 70.5% in EPS; 71.4% in PDS; 82.6% in overlapping, in the 12th month (p>0.05)). Eradicated patients showed significant symptomatic improvement with 70.2% in the 12th month. None of the non-eradicated patients experienced symptomatic improvement.

Table 2. The ratios of symptomatic response after H. pylori eradication therapy among FD Rome IV subgroups that received therapy, at 2nd, 6th, 12th month visits
Subgroups	In EPS cases Responsive(n) / Total(n) (%)	In PDS cases Responsive(n) / Total(n) (%)	In overlapping cases Responsive(n) / Total(n) (%)	In all cases Responsive(n) / Total(n) (%)
Respond rate at 2nd month (%)	23/51 (45.1%)	15/39 (38.5%)	11/26 (42.3%)	49/116 (42.2%)
Respond rate at 6th month (%) Respond rate at 12th month (%)	31/46 (67.4%) 31/44 (70.5%)	18/35 (51.4%) 20/28 (71.4%)	18/25 (72%) 19/23 (82.6%)	67/106 (63.2%) 70/95 (73.7%)
FD, functional dyspepsia; PDS, postprandial distress syndrome; EPS, epigastric pain syndrome

Conclusion

Using Rome IV consensus confirmed the data that H. pylori plays a notable role as a pathogenic factor in FD, particularly in EPS, and it is recommended to screen all FD subgroups, particularly EPS, for H. pylori and eradicate, if detected. Additionally, this study suggests that regions with a high H. pylori prevalence tend to have a higher H. pylori-associated dyspepsia prevalence.

References

1. Wauters L, Dickman R, Drug V, et al. United European Gastroenterology (UEG) and European Society for Neurogastroenterology and Motility (ESNM) consensus on functional dyspepsia. United European Gastroenterol J. 2021 Apr;9(3):307-331.
2. Houte KVD, Carbone F, Goelen N, et al. Effects of Rome IV Definitions of Functional Dyspepsia Subgroups in Secondary Care. Clinical Gastroenterology and Hepatology 2021;19:1620–1626.
3. Carbone F, Vanuytsel T, and Tack J. Analysis of Postprandial Symptom Patterns in Subgroups of Patients With Rome III or Rome IV Functional Dyspepsia. Clinical Gastroenterology and Hepatology 2020;18:838–846.
4. Vanheel H, Vanuytsel T, Van Oudenhove L, Farre R, Verbeke K, Tack J. Postprandial symptoms originating from the stomach in functional dyspepsia. Neurogastroenterol Motil 2013;25:911-e703
5. Ford AC, Tsipotis E, Yuan Y, Leontiadis GI, Moayyedi P. Efficacy of Helicobacter pylori eradication therapy for functional dyspepsia: updated systematic review and meta-analysis. Gut. 2022 Jan 12:gutjnl-2021-326583. doi: 10.1136/gutjnl-2021-326583.
6. Kang SJ, Park B, Shin CM. Helicobacter pylori Eradication Therapy for Functional Dyspepsia: A Meta-Analysis by Region and H. pylori Prevalence. J Clin Med. 2019 Aug 28;8(9):1324. doi: 10.3390/jcm8091324.
7. Malfertheiner P, Megraud F, Rokkas T, et al. European Helicobacter and Microbiota Study group. Management of Helicobacter pylori infection: the Maastricht VI/Florence consensus report. Gut. 2022 Aug 8:gutjnl-2022-327745. doi: 10.1136/gutjnl-2022-327745.

Disclosure

The authors declare that they have no conflict of interest.

Clinical Case Summary

A 67-year-old man initially presented in 2020 with intermittent dysphagia for solid food. An endoscopy of the upper gastrointestinal tract revealed an inflammatory, presumed peptic stenosis at the level of the Z-line. No hiatus hernia was present. A balloon dilatation was performed and therapy with proton pump inhibitors was started. This maintained remission until 2023, when he represented with frequent bolus retention, retrosternal chest pain and regurgitation. A repeat endoscopy appeared normal; however, biopsies revealed lymphocytic esophagitis. A high-resolution oesophageal manometry was performed to clarify the cause of dysphagia. Water swallows showed no abnormal findings; however, the patient had repeated, symptomatic outlet-obstruction during the solid test meal. This finding is often seen in eosinophilic esophagitis.¹ The diagnosis of primary lymphocytic esophagitis, considered to be a variant of this condition,² was proposed. Treatment with oro-dispersible budesonide (1mg bid) was started.
At the same time, an abnormal AV conduction pattern was noted on ECG. Echocardiography and a cardiac stress test were normal; however, CT imaging showed bihilar lymphadenopathy with peri-lymphatic pulmonary nodules. Broncho-alveolar lavage showed lymphocytic alveolitis (29% lymphocytes) and an elevated CD4/CD8 ratio (ratio = 4). ACE (51 U/l) was normal and granulomas were not seen on fine needle aspiration of the lymph nodes; however, the diagnosis of stage 2 pulmonary sarcoidosis was confirmed on PET-CT. Oral prednisolone (30mg od) replaced locally active steroids. The patient was symptom free after one month treatment.
Sarcoidosis is a granulomatous disease that often affects the lungs, skin and lymph nodes; however, involvement of the digestive tract is rare, and secondary lymphocytic esophagitis has hardly ever been described.³ The investigation, primary or secondary aetiology, and management of dysphagia in this case of lymphocytic esophagitis will be discussed.

References

1. Sykes C, Fairlamb G, Fox M, et al. Assessment of Esophageal Motility in Patients With Eosinophilic Esophagitis: A Scoping Review. J Clin Gastroenterol 2023;57:10-30.
2. Greuter T, Straumann A, Fernandez-Marrero Y, et al. Characterization of eosinophilic esophagitis variants by clinical, histological, and molecular analyses: A cross-sectional multi-center study. Allergy 2022;77:2520-2533.
3. Brito-Zeron P, Bari K, Baughman RP, et al. Sarcoidosis Involving the Gastrointestinal Tract: Diagnostic and Therapeutic Management. Am J Gastroenterol 2019;114:1238-1247.

Disclosure

None of the authors have any conflict of interest to disclose

Clinical Case Summary

Closure of mucosal defects after endoscopic submucosal dissection (ESD) may reduce the risk of postprocedural perforation and bleeding. However, defect closure with traditional through-the-scope (TTS) or over-the-scope (OTS) clips and OTS suturing devices may be technically limited by defect size and location. The development of a new through-the-scope helix tack suture system (TTSS) has emerged as a promising tool for overcoming these limitations, particularly when combined with TTS clips.

We present two cases of gastric ESD defect closure with TTSS and adjunctive TTS clip application, highlighting the outcomes and main challenges to achieve complete defect closure.

CASE 1: 73-year-old woman with a 15mm Paris 0-IIb dysplastic lesion of the posterior wall of the antrum. En-bloc ESD was performed and the 25mm mucosal defect was closed with TTSS in a ‘Z’ pattern. However, suboptimal tack placement resulted in incomplete closure of the central portion of the scar, leaving two areas of exposed submucosa at the edges. Complete defect closure was accomplished with the additional placement of four TTS clips at the edges, only possible due to the previously achieved proximity.

CASE 2: 55-year-old man referred for ESD of a 13mm Paris 0-IIa dysplastic lesion in the lesser curvature of the antrum. En-bloc ESD was accomplished, and the resulting 25mm mucosal defect was closed using TTSS in a 'Z' pattern. Complete defect closure was achieved with the additional placement of one TTS clip.

Both patients were discharged the following day and presented with no complications at 1-month follow-up.

These cases highlight the potential of TTSS becoming a practical solution for the closure of complex post-ESD defects, allowing earlier patient discharge. While this novel TTSS with adjunctive TTS clip application appears to be effective in the management of sizable defects, proper suture pattern and tack placement are paramount for achieving complete defect closure.

References

1. Kobara H, Tada N, Fujihara S, Nishiyama N, Masaki T. Clinical and technical outcomes of endoscopic closure of postendoscopic submucosal dissection defects: Literature review over one decade. Dig Endosc. 2023 Jan;35(2):216-231.
2. Hernandez-Lara A, Garcia Garcia de Paredes A, Rajan E, Storm AC. Step-by-step instruction: using an endoscopic tack and suture device for gastrointestinal defect closure. VideoGIE. 2021;6(6):243-245.
3. Hernandez A, Marya NB, Sawas T, Rajan E, Gades NM, Wong Kee Song LM, et al. Gastrointestinal defect closure using a novel through-the-scope helix tack and suture device compared to endoscopic clips in a survival porcine model (with video). Endosc Int Open. 2021 Apr;9(4):E572-E577.
4. Canakis A, Dawod SM, Dawod E, Simons M, Di Cocco B, Westerveld DR, et al. Efficacy, Feasibility, and Safety of the X-Tack Endoscopic HeliX Tacking System: A Multicenter Experience. J Clin Gastroenterol. 2024 Jan 29.
5. Canakis A, Deliwala SS, Frohlinger M, Twery B, Canakis JP, Shaik MR, et al. Endoscopic outcomes using a novel through-the-scope tack and suture system for gastrointestinal defect closure: a systematic review and meta-analysis. Endoscopy. Published online March 22, 2024.

Introduction

Diagnostics of enteropathy with membrane digestion disturbance (EMDD) is based on the evaluation of carbohydrase activity in duodenal mucosa (DM). There is no information about diagnostic value of ileum mucosa (IM) carbohydrases.
Study objective. Assess the diagnostic value of carbohydrases activity in mucous membrane of duodenum and distal ileum in patients with EMDD and irritable bowel syndrome (IBS).

Aims & Methods

The study includes 12 patients with EMDD, 16 patients with IBS and 12 relatively healthy persons (control group). Study design included analysis of food tolerance and evaluation of activity of sucrase (S), glucoamylase (GA), maltase (М) and lactase (L) in mucous membrane of duodenum and ileum based on the method of Dahlquist with N.I.Belostotsky modification. Microsoft Office Excel and STATISTICA 10.0 were used for statistical evaluation of material. Mann-Whitney criterion was used to evaluate the differences between quantitative parameters. The differences were considered to be significant at p <0.05. Control group was used for comparison.

Results

Ratio of carbohydrase activity in duodenum and ileum in control group and patients with IBS and EMDD.

In control group the carbohydrases activity in duodenum mucosa was not significantly statistically different from the one in ileum mucosa.
In patients with IBS glucoamylase and maltase activity parameters in IM were significantly different from activity in DM, which can be interpreted as functional inequality of enzyme activity of various departments of small intestine.
In patients with EMDD GA level in ileum mucosa is 5.2 times higher, maltase level is 3.8 times higher and sucrose level is 2 times higher than duodenum enzyme levels, which demonstrates the possibility of formation of compensatory reaction of adaptive shift type towards distal segments of small intestine, initially described by A.M. Ugolev et al. in 1985

Conclusion

Enzyme activity distribution along small intestine is an adaptor function of its segments. Our study confirmed the need and promising outlook of further investigations in terms of evaluation of proximo-distal gradients of enzyme activity to study compensatory reactions which can be fulfilled by distal segment of small intestine in case of duodenum damage.
The evaluation of carbohydrase activity in ileum mucosa provides additional opportunities for diagnostics of EMDD and its differentiation from IBS, which can be used to improve therapeutic approaches.

Clinical Case Summary

We report the case of a 64-year-old man with preexisting hepatic sarcoidosis complicated by liver cirrhosis, who presented with confusion as an initial manifestation of COVID-19 confirmed by rapid Antigenic test. His Child Pugh score was 8 (Class B) and MELD was 16. Chest radiographs showed bilateral patchy interstitial opacities. Computed tomography (CT) of the brain was normal. Lumbar puncture was not performed because of a marked thrombocytopenia. Urine cytobacteriological examination did not show a urinary tract infection. An abdominal ultrasound showed normal hepatoportal flow and a mild ascites. Ascitic fluid analysis did not show spontaneous bacterial peritonitis. Since the patient was cirrhotic, we have considered the diagnosis of hepatic encephalopathy as a possible explanation for the neurological symptoms, so he started Lactulose and Rifaximin. However, his clinical condition showed no improvement, the neurological disorders remained the same. A brain MRI showed in FLAIR MR sequences a few hyperintensities punctiform in the white matter of the supratentorial region and the subcortical of the left insula region. There were no signs of a cerebral granuloma nor toxoplasmosis. It did not show venous thrombosis. There were no microheamorragies neither ischemic lesions. After careful evaluation by neurologic experts, encephalitis associated with SARS-CoV-2 infection was concluded. The patient was treated by intravenous Dexamethasone and he fully recovered without sequelae. This case illustrates the fact that neurological manifestations associated with COVID-19 infection are not necessarily a reflection of critical illness, and should incite clinicians to actively look for any evidence of COVID-19 infection as a differential diagnosis in patients with preexisting cirrhosis, presenting with neurological symptoms, during the epidemic period of COVID-19.

Introduction

The prevalence of functional dyspepsia (FD) and gastroparesis in diabetic patients remains unknown. A high prevalence of gastroparesis has been reported in diabetic patients reaching up to 5%.¹ However, recent consensus specified the symptom pattern for gastroparesis, with nausea and/or vomiting as predominant symptoms, now defined as “gastroparesis-like symptoms” (GPLS).² The global prevalence of GPLS has been estimated to reach only 1.2% in diabetic patients, but type 1 and type 2 diabetes were not assessed separately.²

Aims & Methods

We aimed to assess the prevalence and burden of FD and GPLS in primary care patients with diabetes, comparing patients with type 1 and type 2 diabetes. An online survey was addressed to diabetic patients through general practitioners and diabetic patient associations. The survey included the Rome IV questionnaire and the Patient Assessment of Gastro-Intestinal Disorders-Symptom Severity Index (PAGI-SYM) for upper gastro-intestinal symptoms. Anxiety, depression, somatization, and quality of life were also assessed by specific questionnaires (Generalized Anxiety Disorder GAD-7, Patient Health Questionnaire PHQ-9, PHQ-15, and PAGI-QoL questionnaires respectively).

Results

A total of 216 patients completed the questionnaires, among which 146 had type 1 diabetes, and 68 had type 2 diabetes, (2 patients did not know their type of diabetes). The median age of the population was 56 (50-61) years old, with 134 female patients (61.8%). The prevalence of FD was 13.0% with no difference between the 2 groups. The prevalence of GPLS reached 4.2% and was significantly higher in patients with type 2 diabetes (8.9% vs 2.1%; p=0.03). The burden of upper gastro-intestinal symptoms and their impact on quality of life was higher in type 2 diabetes patients with higher PAGI-SYM and PAGI-QoL scores while anxiety and somatization were not different between type 1 and type 2 diabetes patients (see Table). Overall, patients with GPLS had higher anxiety (9 vs 3; p=0.003), depression (12 vs 3; p=0.001) and somatization scores (16 vs 6; p<0.001) than patients without. Compared to patients with FD without GPLS, GPLS patients had numerically higher but not statistically different scores for symptom severity (51 vs 28; p=0.46), anxiety (9 vs 7; p=0.29), depression (12 vs 7; p=0.07), somatization (16 vs 11.5; p=0.16) and quality of life scores (52 vs 24; p=0.16).

	Type 1 diabetes (n=146)	Type 2 diabetes (n=68)	p value
Age	39 (29–51)	60 (50–67)	<0.001
Sex (female)	99 (67.8%)	35 (51.4%)	0.02
Functional dyspepsia PDS EPS	18 (12.3%) 17 (11.6%) 3 (2.1%)	10 (14.7%) 10 (14.7%) 3 (4.4%)	0.66 0.52 0.38
Gastroparesis-like symptoms	3 (2.1%)	6 (8.9%)	0.03
GAD-7 (Anxiety)	4 (1–6)	3 (0–7)	0.80
PHQ-9 (Depression)	3 (1–7)	3 (1–10)	0.05
PHQ-15 (Somatization)	7 (3.3–10)	8 (4–13)	0.10
PAGI-SYM	6.5 (1–8.8)	9.5 (2–35.5)	0.009
PAGI-QoL	6 (0–15.3)	10 (3–38)	0.003

Conclusion

This study confirms that the prevalence of GPLS seems to be higher in diabetic patients compared to available population data, especially in patients with type 2 diabetes. The impact of the symptoms was similar to the impact of FD in this population. Further studies are required to assess the prevalence of delayed gastric emptying in diabetic type 1 and 2 patients with GPLS.

References

1. Choung RS, Locke GR, Schleck CD, et al. Risk of Gastroparesis in Subjects with Type 1 and 2 Diabetes in the General Population. Am J Gastroenterol 2012;107:82-88.
2. Huang I-H, Schol J, Khatun R, et al. Worldwide prevalence and burden of gastroparesis-like symptoms as defined by the United European Gastroenterology (UEG) and European Society for Neurogastroenterology and Motility (ESNM) consensus on gastroparesis. United European Gastroenterol J 2022;10:888-897.