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

Clinical Case Summary

Intra-ampullary papillary tubular neoplasms (IAPNs) are rare neoplastic intraepithelial lesions that occur within the ampulla. Given their well-documented malignant potential, early recognition and intervention are paramount to prevent malignant transformation. We present a case of IAPN successfully managed via endoscopic papillectomy.
A 58-year-old male was incidentally found to have a bulky-appearing ampulla of vater during esophagogastroduodenoscopy as part of routine health screening. Endoscopic ultrasonography revealed a 20-mm hyperechoic lesion at the ampulla, with histopathological evaluation demonstrating low-grade dysplasia (indeterminate for neoplasia). Laboratory investigations, including hematological parameters, biochemical profiles, and tumor markers, were within normal limits. Contrast-enhanced abdominal CT demonstrated a well-defined, homogeneously enhancing 20-mm lesion at the ampullary region without biliary/pancreatic duct dilation.
Endoscopic papillectomy was performed using a duodenoscope with snare. Prophylactic stents were placed in both the biliary and pancreatic ducts to ensure adequate drainage. Any intraprocedural bleeding was promptly controlled with hemoclip application. Histopathological analysis confirmed high-grade IAPN, characterized by a polypoid tumor with closely packed tubular glands lined by pseudostratified columnar epithelium showing loss of polarity and moderate nuclear atypia (Ki-67 index: 50%). The postoperative course was uncomplicated, with discharge achieved on the sixth postoperative day. At six-month follow-up evaluation, surveillance endoscopic ultrasonography showed no evidence of recurrence.
IAPN represents a distinct neoplastic ampullary entity within the spectrum of ampullary tumors. While endoscopic resection demonstrates therapeutic efficacy, its implementation requires advanced endoscopic expertise in specialized centers.

References

Endoscopic ultrasonography revealed a 20-mm hyperechoic lesion at the ampulla
Endoscopic papillectomy was performed using a duodenoscope with snare. Prophylactic stents were placed in both the biliary and pancreatic ducts to ensure adequate drainage. Any intraprocedural bleeding was promptly controlled with hemoclip application.
Histopathological analysis confirmed high-grade IAPN, characterized by a polypoid tumor with closely packed tubular glands lined by pseudostratified columnar epithelium showing loss of polarity and moderate nuclear atypia (Ki-67 index: 50%).

Introduction

Computer-aided detection (CADe) systems improve adenoma detection rate (ADR). However, there is some concern that the long-term use of CADe systems might lead to a decline in endoscopists’ independent detection skills, particularly their ability to detect lesions without assistance—a phenomenon referred to as "deskilling".

Aims & Methods

This study aims to evaluate the impact of CADe on the learning curve of endoscopists for ADR. This was a propensity score–matched (PSM), prospective, single-center, observational study conducted at a tertiary care hospital from January 2021 to December 2023. CADe systems were installed in half of the endoscopy units, and patients were equally distributed between the rooms. Patients in CADe-equipped rooms were examined using EndoBRAIN-EYE (Olympus Corp, Tokyo, Japan). Patients aged ≥ 20 years scheduled for colonoscopy were included, excluding those with polyposis, inflammatory bowel disease, known polyps, incomplete colonoscopy, emergency cases, previous colorectal surgery, and examination by novices. Endoscopists were classified as high-detectors (ADR ≥ 25%) or low-detectors (ADR < 25%) based on the ADR recorded before CADe implementation. The primary outcome was to evaluate the learning effect of CADe using cumulative summation (CUSUM) analysis based on ADR during both CADe and non-CADe procedures to assess skill acquisition and transfer. The CUSUM scores were calculated from the acceptable probability of failure and unacceptable probability of failure. Acceptable and unacceptable ADR were defined as 40% and 30% for high detectors, and 35% and 25% for low detectors, respectively. Performance was judged based on the boundary lines (h0 and h1): acceptable if the CUSUM plot fell below h0, unacceptable if it went above h1, and inconclusive requiring further observation if it stayed between these boundaries. The secondary outcomes included ADR, advanced adenoma detection rate (AADR), and sessile serrated lesion detection rate (SSLDR). The study received ethics approval (no.19H072) and complied with the Declaration of Helsinki.

Results

Out of 5,717 patients initially enrolled, 4,712 patients (2,356 in CADe group and 2,356 in non-CADe group) were analyzed after PSM for known factors (age, sex, indication, and bowel preparation). During CADe-assisted procedures, both high-detectors and low-detectors showed patterns below the acceptable performance line (h0), indicating improved adenoma detection performance with AI support. However, during non-CADe procedures, the patterns diverged significantly. For high-detectors, their CUSUM plots consistently fell below the acceptable performance line (h0) over time during non-CADe colonoscopies, indicating that they successfully acquired and maintained improved adenoma detection skills even without AI assistance. In contrast, the CUSUM plots of the low-detectors remained between the acceptable (h0) and unacceptable (h1) limits throughout the study period, showing no significant change in learning trajectory during non-CADe procedures. The CADe group had a significantly higher ADR (40.5% [95% CI: 38.5-42.5%]) compared to non-CADe group (32.4% [95% CI: 30.5-34.4%]; p < 0.001). SSLDR was also significantly higher in the CADe group (6.9% [95% CI: 5.9-8.0%] vs. 4.5% [95% CI: 3.7-5.4%]; p = 0.001), while AADR showed no significant difference (4.1% [95% CI: 3.4-5.0%] vs. 4.7% [95% CI: 3.9-5.6%]; p = 0.39).

Conclusion

The implementation of the CADe system did not result in deskilling regarding adenoma detection.

Disclosure

The conflict of interests were following: Shin-ei Kudo and Masashi Misawa received speaking honoraria from Olympus Corporation and have an ownership interest of the products of Cybernet Systems. Kensaku Mori received research grants from Cybernet Systems, Morita Mfg, Atom Medical Inc, and Asahi Intecc. Additionally, Kensaku Mori serves as a Technical Advisor for Sanyu Industry. Tetsuo Nemoto received a research grant from Olympus Corporation for other studies. Other authors have nothing to declare.

Clinical Case Summary

Introduction: Dieulafoy lesions account for less than 2% of gastrointestinal bleeds, and only 20% of these occur outside the stomach. We present a rare case of a bleeding ampullary Dieulafoy lesion with technical difficulties in management, starting with a standard forward-viewing gastroscope, subsequent use of a side-viewing duodenoscope, and eventually endoscopic retrograde cholangiopancreatography (ERCP) and stenting to allow for safe haemostasis with argon plasma coagulation (APC).
Case report: A 56-year-old male was admitted with pneumonia and fluid overload in the context of end-stage renal disease from poorly controlled diabetes mellitus and hypertensive nephrosclerosis on regular haemodialysis. He was on dual anti-platelet therapy with aspirin and ticagrelor for a recent cardiac stent.
Five days into his admission he was noted to have melena with a haemoglobin drop from 87 g/L to 56 g/L, with a urea rise of 23.9 mmol/L from a baseline of 11.0 mmol/L.
Subsequent gastroscopy revealed active bleeding from the major ampulla without any underlying ulcer or tumour, superior to the biliary orifice, consistent with an ampullary Dieulafoy lesion. The duodenoscope was then introduced for a better view and access to the major ampulla. APC was attempted at 0.8 L/min at 30 Watts due to the size and location, but haemostasis was unsuccessful.
The decision was made to proceed to ERCP and biliary stenting to prevent complications from heat injury to the bile duct and possible pancreatitis. A 7 Fr by 4 cm double pigtail biliary plastic stent was placed into the common bile duct. APC was re-applied at 0.8 L/min at 30 Watts at the bleeding spot with successful haemostasis.
Discussion: This case report aims to highlight the rare occurrence of duodenal ampullary Dieulafoy lesions and the need for prompt recognition and use of resources such as side-view duodenoscopy and ERCP for safe therapeutic management.

Disclosure

None

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.

Introduction

Endoscopic papillectomy(EP)is a viable treatment option for ampullary lesions(AL).While many studies have reported low morbidity and acceptable outcomes, early attempts to pool data from these initial experiences have produced conflicting conclusions regarding key technical aspects. To address these uncertainties, we conducted a systematic review and pooled analysis to evaluate the safety and efficacy of EP for AL,identifying factors that may influence outcomes.

Aims & Methods

Electronic databases(Medline, Scopus and EMBASE)were searched up to September 2024. Studies that included patients with endoscopically resected AL were eligible. Efficacy and safety outcomes were pooled by means of a random-effects model to obtain a proportion with a 95% confidence interval(CI). Univariable meta-regression analyses were conducted to explore potential factors affecting outcomes.

Results

A total of 60 studies(4,859 lesions)published between 2002 and 2024 were analyzed. Complete resection was achieved in 86.2%of cases, though intraductal involvement limited success. The recurrence rate was 18.6%, however, the majority(89.3%)of patients were managed endoscopically without surgery. The pooled adverse event(AE)rate was 30.0%, with bleeding(12.2%)and post-procedural pancreatitis(11.1%)being the most common complications. Prophylactic stenting reduced pancreatitis risk, while intraductal involvement increased perforation risk.Adjunctive treatments for intraductal involvement were associated with an increased risk of papillary stricture.

Conclusion

Endoscopic papillectomy is a safe and effective treatment for ampullary lesions. However, lesions with intraductal extension pose a higher risk of incomplete resection and perforation, warranting careful evaluation of the benefit-risk balance in these cases. While prophylactic pancreatic stenting may reduce the incidence of post-procedural pancreatitis, optimizing strategies to minimize overall adverse events remains a key focus for future research.