Introduction

According to guidelines, in order to strictly diagnose esophageal motility disorders, besides achalasia, high resolution manometry (HRM) findings should be documented in both the upright and the supine position. A common finding among patients with Gastro-Esophageal Reflux Disease GERD submitted to manometry is ineffective esophageal motility (IEM). The clinical impact of such a diagnosis in this setting is ambiguous though it may denote future disturbance of peristaltic reserve even if until now only inadequate response to multiple rapid swallows (MRS) has been correlated to post anti-reflux surgery dysphagia.

Aims & Methods

We aimed to evaluate differences in esophageal contractility in different positions in patients with definite GERD.We included consecutive patients with definite GERD according to Acid Exposure Time (>6%) submitted simultaneously to 24 hours pH impedance off PPI study and HRM in both the upright and supine position. Patients with previous esophago-gastric surgeries as also patients diagnosed with motility disorders besides IEM/absent contractility according to Chicago 4 guidelines were excluded.

Results

In total 49 patients (M/F:26 (53.1%)/23 (46.9%), mean age:51±14) were included. The main referral reason was typical reflux symptoms in 37/49 (75.5%) patients while 8/49 (16.3%) reported dysphagia. Mean Distal Contractile Integral (DCI) was significantly reduced in the upright position (1629.2±1175.6 mm²/s/mmHg) vs supine position (2762.4±2710.4 mm²/s/mmHg), p=0.010. The rate of total ineffective swallows in the upright position was significantly increased in the upright position (29.0%) vs the supine (12.3%), p=0.010 as was also the rate of weak contraction (10.3% vs 3.1%, p=0.033 ) and marginally not of absent contractions (17.0% vs 8.3%, p=0.078). The rate of diagnosis of IEM/absent contractility was doubled in the upright position (8/49, 16.3%) vs in the supine position (4/49, 8.2%) (k-value:0.473, p=0.001). Inadequate post MRS contraction was observed in 9/49 (18.4%) and more specifically among 3/4 (75%) patients with IEM/absent contractility diagnosis in the supine position (k:-0.436, p=0.002) vs 4/8 (50%) in the upright position (k:-0.361, p=0.011). Dysphagia was not correlated to diagnosis of IEM/absent contractility neither in the supine (p=0.675) nor the upright position (p=0.586).

Conclusion

Upright position in HRM is correlated to a decreased mean DCI and an increased rate of ineffective esophageal contractions leading to an increased rate of diagnosis of IEM/absent contractility. Such a diagnosis in the upright position is correlated in a lesser extent to inadequate post-MRS swallow and not correlated to symptom of dysphagia. Until new data arise such an overdiagnosis among patients with GERD may be misleading and therefore the procedure in such patient may be better to be undertaken only in the supine position.

Introduction

Helicobacter pylori is a common cause of peptic ulcers and gastritis. Standard triple therapy includes a PPI with amoxicillin and either clarithromycin or levofloxacin. Rising antibiotic resistance has reduced its effectiveness. Sequential therapy offers a phased alternative with better outcomes in resistant cases.

Aims & Methods

To evaluate and compare the efficacy of clarithromycin and levofloxacin-based triple and sequential therapies for Helicobacter pylori (H. pylori) eradication in a resource-limited setting, in the context of emerging antibiotic resistance.
A prospective, randomized study was conducted at a tertiary care center from January 1, 2022, to January 1, 2025. A total of 300 treatment-naïve patients aged 18–60 years, diagnosed with H. pylori infection through stool antigen, urea breath test, or histology, were included. Patients with prior eradication therapy or recent antibiotic use were excluded. Participants were randomized into four equal groups (n=75 each):

• Clarithromycin-based triple therapy (amoxicillin, clarithromycin, PPI)
• Levofloxacin-based triple therapy (amoxicillin, levofloxacin, PPI)
• Clarithromycin-based sequential therapy (amoxicillin + PPI for 5 days, followed by clarithromycin + tinidazole + PPI for 5 days)
• Levofloxacin-based sequential therapy (amoxicillin + PPI for 5 days, followed by levofloxacin + tinidazole + PPI for 5 days) Therapeutic response was assessed post-treatment for eradication.
  

Results

Out of 300 patients (180 males, 120 females), eradication was achieved in:

• 48/75 (64%) in clarithromycin-based triple therapy
• 53/75 (70.7%) in levofloxacin-based triple therapy
• 51/75 (68%) in clarithromycin-based sequential therapy
• 61/75 (81.3%) in levofloxacin-based sequential therapy

All patients completed therapy without notable adverse events or compliance issues. Lower eradication rates in clarithromycin-based regimens suggest rising resistance.

Conclusion

Levofloxacin-based sequential therapy demonstrated the highest eradication rate, highlighting its potential as a preferred regimen in settings with rising clarithromycin resistance. Clarithromycin-based treatments showed suboptimal outcomes, emphasizing the need for region-specific antibiotic stewardship and resistance surveillance.

References

1. Kim JS, Kim BW, Hong SJ, Kim JI, Shim KN, Kim JH, Baik GH, Kim SW, Song HJ, Kim JH. Sequential Therapy versus Triple Therapy for the First Line Treatment of Helicobacter pylori in Korea: A Nationwide Randomized Trial. Gut Liver. 2016 Jul 15;10(4):556-61. doi: 10.5009/gnl15470. PMID: 27114421; PMCID: PMC4933415.
2. Chang, J.Y., Shim, KN., Tae, C.H. et al. Triple therapy versus sequential therapy for the first-line Helicobacter pylori eradication. BMC Gastroenterol 17, 16 (2017). https://doi.org/10.1186/s12876-017-0579-8

Introduction

Celiac disease (CD) is an autoimmune enteropathy induced by the ingestion of gluten in genetically predisposed individuals. Although its clinical expression is most often digestive, extra-digestive manifestations can occur, among which thromboembolic complications, although rare, deserve particular attention.
The aim of this study is to describe the profiles of coeliac patients with thromboembolic complications, analyze their clinical, paraclinical and etiological characteristics, and discuss the underlying pathophysiological mechanisms.

Aims & Methods

This is a retrospective, descriptive, monocentric study conducted in the hepato-gastroenterology department of Ibn Sina Hospital in Rabat over a 30-year period, from 1995 to 2025. The records of 344 patients followed for celiac disease were reviewed. Patients with one or more documented thromboembolic complications during follow-up were included in the study. Clinical, biological, endoscopic and histological data were collected and analyzed.

Results

Of a total of 344 patients followed for celiac disease in the department, 5.5% (n=19) developed a thromboembolic complication during follow-up. The population concerned was predominantly female, with 89.5% women (n=17) versus only 10.5% men (n=2). The mean age at the time of complication was 39.6 years, with a median of 35.5 years, and extremes ranging from 18 to 62 years.
Endoscopic exploration (oesogastro duodenal fibroscopy) in these patients showed lesions suggestive of celiac disease in 68.4% (n=12), while it was non-specific in 31.6% (n=6), and normal in 5.3% (n=1). Histologically, villous atrophy was found in all patients, with 78.9% (n=15) showing total atrophy (Marsh IIIc) and 21.1% (n=4) subtotal atrophy (Marsh IIIb).
As regards thromboembolic manifestations, portal vein thrombosis was the most frequent complication, observed in 57.9% of cases (n=11). It was followed by deep vein thrombosis of the lower limbs, reported in 15.8% of cases (n=3), and ischemic stroke in 10.5% (n=2). Isolated cases of thrombosis of the inferior vena cava, axillary vein and femoral vein were recorded, each accounting for 5.3% of cases (n=1).
The etiological study revealed hyperhomocysteinemia in 36.8% of patients (n=7) and protein C and/or S deficiency in 21.1% (n=4). In the remaining 42.1% of patients (n=8), the thrombophilia work-up was normal, suggesting that celiac disease itself was the cause of the thrombotic event.
Therapeutically, all patients were treated with oral anticoagulation. One patient required a vena cava filter because of the risk of bleeding on anticoagulation, and another underwent surgical treatment for axillary thrombosis. The outcome was favorable in all cases, with no recurrence or major complication during follow-up.

Conclusion

Thromboembolic complications in celiac disease are rare but potentially serious. This study highlights the predominance of women, the diversity of thrombotic localizations, and the possible involvement of hyperhomocysteinemia and C/S protein deficiencies. In almost half the cases, no thrombophilic cause has been identified, suggesting a role for celiac disease in the genesis of these events. Clinical vigilance is essential, particularly in cases of late diagnosis or poor compliance with the gluten-free diet.

Introduction

Branch-duct intraductal papillary mucinous neoplasms (BD-IPMNs) are frequently associated with acute (AP) or recurrent pancreatitis (RP), likely due to the mucin-induced obstruction of the main pancreatic duct (MPD). According to the 2024 Kyoto Guidelines, pancreatitis represents an indication for surgical evaluation in IPMN patients. However, pancreatic sphincterotomy (PS) may represent a less invasive alternative for patients who are unfit for surgery or as a bridge to surgery, aiming to reduce the risk of further pancreatitis episodes.

Aims & Methods

This single-center retrospective study aimed to assess the efficacy and safety of PS in patients with BD-IPMN and RP. We included 33 patients who underwent PS between 2016 and 2023, with at least 12 months of follow-up. Patients with other causes of RP or prior pancreatic surgery were excluded. The frequency of pancreatitis episodes before and after PS was compared. Clinical success was defined as complete resolution or ≥50% reduction in pancreatitis episodes. Adverse events, presence of worrisome features (WF), and progression to high-risk stigmata (HRS) were evaluated. Statistical analysis was performed using paired t-test and Fisher’s exact test, with p < 0.05 considered significant.

Results

Among the 33 patients analyzed (39.4% female, 60.6% male, mean age 59 ± 13.9 years) clinical success was achieved in 81.8% of the cases. Specifically, 72.7% of the patients experienced no further AP episodes after PS and 9.1% experienced a reduction in episode frequency, while 18.2% of patients did not respond to treatment. Adverse events occurred in 15% of patients, including: 12% with post-ERCP pancreatitis (all mild) and 3% with intra-procedural bleeding; no perforations were reported. During follow-up WF emerged in 5 patients (15%), while no cases of HRS were identified. Among the 6 non-responders, 3 underwent a second PS, with 2 achieving clinical improvement, and 3 underwent duodenocephalopancreasectomy (DCP), including 1 for a concomitant pancreatic ductal adenocarcinoma (PDAC) unrelated to IPMN progression. Notably, no cases of IPMN degeneration were observed in the series

Conclusion

Pancreatic sphincterotomy appears to be a safe and effective approach for managing recurrent pancreatitis in patients with BD-IPMN, potentially reducing the need for surgery in selected cases.

Clinical Case Summary

Introduction: Pancreatic involvement in non-Hodgkin lymphomas is rare and often mimics pancreatic adenocarcinoma. We report a case in which endoscopic ultrasound (EUS) was pivotal in establishing the correct diagnosis.
Case Presentation: A 39-year-old male, a chronic smoker, presented with jaundice, anorexia, and fever. Laboratory findings revealed hepatocellular injury and cholestasis (total bilirubin: 15 mg/dL; GGT: 868 U/L; ALP: 679 U/L). CT imaging (Figure 1) demonstrated a large retroperitoneal mass infiltrating both the pancreas and adjacent vascular structures, associated with ascites and omental thickening. EUS (Figure 2) revealed a hypoechoic, poorly defined mass in the head and body of the pancreas (65×55 mm), with evidence of vascular invasion. A fine-needle biopsy (22G) was performed. Endoscopic Retrograde Cholangiopancreatography (ERCP) confirmed malignant duodenal stenosis. Histopathology was consistent with diffuse large B-cell lymphoma (DLBCL). The patient was initiated on R-CHOP chemotherapy (Rituximab, Cyclophosphamide, Hydroxydaunorubicin, Oncovin, Prednisone) after baseline staging. Eight months later, follow-up EUS (Figure 3) showed no residual pancreatic mass.
Discussion: In atypical pancreatic masses—especially in younger patients with systemic symptoms—EUS is essential for tissue acquisition and accurate differential diagnosis. Unlike adenocarcinoma, pancreatic lymphomas respond well to chemotherapy.
Conclusion: Early use of EUS in atypical pancreatic masses can prevent misdiagnosis, reduce time to treatment, and avoid unnecessary surgical interventions.

References

Figure 1 - retroperitoneal mass infiltrating pancreas and vascular structures
Figure 2 - hypoechoic, poorly defined mass in the head and body of the pancreas
Figure 3 - no residual pancreatic mass

Introduction

Data about the effectiveness and safety of vonoprazan (VPZ) as an adjuvant for treating H. pylori are lacking in Brazil. Previous studies suggest that greater acid suppression might improve effectiveness, with an acceptable eradication rate around 90%.

Aims & Methods

To evaluate VPZ in eradication therapy in Brazil, as part of the Hp-BrazilReg, WorldHpReg's partner, a multicenter and prospective real-life registry was performed, assessing outcomes of H. pylori management by Brazilian gastroenterologists. Data were registered at e-CRF AEG-REDCap from March 2022 to October 2024. The effectiveness was assessed by modified intention-to-treat (mITT) analysis. Data were subject to quality review.

Results

2,132 Brazilian patients, with a mean age of 52 years, 61% of whom were women, were included in the mITT analysis. The main treatment indications were: 63% dyspepsia, 10% gastroduodenal ulcers, and 5% premalignant gastric lesions. Endoscopy was performed in 95% of the cases, using histology (90%) and/or the rapid urease test (15%) for diagnosing the infection. No pre-treatment bacterial resistance test was performed. First-line treatments were administered to 73% (n=1,560) of cases, second-line to 18% (n=386), and rescue to 9% (n=186), with 94% of patients receiving 14-day prescriptions. Low-dose (between 4.5 and 27mg of omeprazole equivalent BID), standard-dose (between 32 and 40mg of omeprazole equivalent BID), and high-dose (between 54 and 128mg of omeprazole BID) of proton pump inhibitor (PPIs) as well as 20mg BID of vonoprazan (VPZ) were used in 39%, 38%, 23%, and 15% of treatment cases, respectively. Probiotics were used as adjuvant in 15% of patients. Compliance (>90% drug intake) was reported in 99% of the patients. Eradication was mostly confirmed by endoscopy in 88% (histology [74%] and/or rapid urease test [14%]). The ¹⁴C-urea breath test was used in 8% of the cases. At least one adverse event was reported by 25% of patients, mainly nausea (13%), dysgeusia (8%) and diarrhea (7%). The regimens reaching 90% eradication were: dual-VPZ+amoxicillin for first-line and rescue treatments (96% and 100%, respectively), quadruple VPZ+bismuth+tetracycline+metronidazole for second- and third-line treatments (92% and 90% respectively), and quadruple PPI+bismuth+levofloxacin+amoxicillin (100%) for second-line treatment. Prescribing VPZ (vs PPI ) was an independent factor associated with higher effectiveness both in first-line (OR 2.95; IC 95%: 1.71-5.09) and in second-line and rescue treatments (OR 2.87; IC 95%: 1.69-5.13). There was no difference in adverse effects between VPZ and PPI-based regimens (p<0.01).

Conclusion

VPZ, when prescribed as an adjuvant for treating H. pylori infection, shows highly effective results as part of dual therapy with amoxicillin for first-line and rescue treatments, as well as in quadruple therapy with bismuth+metronidazole+ tetracycline or bismuth+amoxycillin and rifabutin for rescue treatments.