Introduction

The brain-gut axis plays a crucial role in the regulation of gastrointestinal (GI) function, with the activity of the autonomic nervous system (ANS) being significantly important. Increased stress, correlated with socioeconomic, behavioral, dietary, and environmental factors, may lead to an overactive sympathetic nervous system response. The aim of this study was to evaluate the correlation between stress and autonomic nervous system responses in gastrointestinal patients.

Aims & Methods

The study comprised 136 GI patients, divided into three groups: the Dyspepsia Group (DG) with 39 patients, a mean age of 37.8 ±11.2 years; the IBS Group (IBS) with 41 patients, a mean age of 45±15 years; and the Celiac Group (CG) with 53 patients, a mean age of 38.2±14 years. ANS activity was assessed using parameters from Heart Rate Variability (HRV) analysis, including time domain, frequency domain, and nonlinear analysis. The severity of stress was assessed using stress indices calculated based on hemodynamic parameters and indicators from linear and nonlinear HRV analysis with the HRV Kubios Premium software.

Results

Patients in the IBS Group exhibited the highest stress indicators and sympathetic ANS activity parameters compared to those in the DG and CG groups (SNS index [stress] p=0.038, SNS index AVG p=0.038). Furthermore, the IBS Group had higher stress indices compared to the DG Group (Stress Index 14.0 vs 9.0; p=0.024). Positive correlations were found between the Stress Index, SNS index (stress), and average heart rate (R=0.525; p=0.0001), as well as with sympathetic ANS activity indices. Negative correlations were observed with indicators of parasympathetic nervous system activity across all investigated groups (R=0.433; p=0.001). A high level of stress, indicated by a Stress Index value above 12, was found in 18% of patients with CD, 38% with IBS, and 28% with DG.

Conclusion

Approximately 27% of GI patients experienced significant levels of stress. The stress indicators positively correlated with sympathetic ANS activation and/either impaired function of the parasympathetic system. Assessing the severity of stress will enable targeted therapy to improve the dysfunctions of the brain-gut axis.

Introduction

This study aimed to compare the efficacy of combined intravenous and oral proton pump inhibitor (PPI) versus oral vonoprazan (VPZ) alone therapy in preventing delayed bleeding (DB) after gastric endoscopic submucosal dissection (ESD) in a consecutive and large case series.

Aims & Methods

A retrospective study at Chiba University Hospital included consecutive patients who underwent gastric ESD between January 2017 and July 2023. Before 2019, patients received intravenous omeprazole 20 mg in the morning and evening on the day of ESD and the day after. Thereafter, esomeprazole 20 mg was administered orally once daily, which was continued for generally 28 days (defined as the PPI group). From 2020 onward, patients received oral VPZ 20 mg once daily starting on the day of ESD, also typically continued for 28 days (defined as the VPZ group). Propensity score generation and 1:1 matching of patients between the PPI and VPZ groups were performed to minimize selection bias in treatment assignment. Matching was based on nine covariates associated with DB rates for gastric ESD, including whether patients were taking warfarin, directly acting oral anticoagulant (DOAC), P2Y12 receptor antagonist, aspirin, or cilostazol; whether it was CKD with haemodialysis, a tumour size >30 mm, lower-third in tumour location and presence of multiple tumours.

Results

There were 720 cases (856 tumors) of gastric ESD during the study period, of which 352 (409 tumors) were in the PPI group and 368 (447 tumors) in the VPZ group. Propensity score matching for 9 covariates related to DB rates for gastric ESD ultimately produced 334 best matches. There was no significant difference in DB rates between the two groups (3.6% vs 3.6%. p = 1.000).

Conclusion

Though further prospective studies are needed to draw definitive conclusions, it was suggested that the easily administered oral VPZ can be an important option for acid suppression after gastric ESD.

Introduction

​Helicobacter pylori is class I carcinogen responsible for 89% of non cardia gastric cancer.

Aims & Methods

Screen and treat application study is ongoing in six EU countries in the asymptomatic age group of citizens from the age of 30 to 34 years. The test-and-treat program is free of charge for all eligible participants. Four different locally validated H. pylori IgG serologies and / or UBT as a test were used. Quadruple bismuth based 14 day, a 10-day regimen with esomeprazole combined with bismuth quadruple therapy in a single-capsule or 14 day tripple eradication therapy were used as the first line therapy. RED Cap IT platform (pretreatment questionnaires, treatment protocols, side effects, compliance,complications…) was used to collect data for quality assurance, monitoring, and evaluation.

Results

The study is still ongoing. Interim results show a wide variation of response rates to the invitation (from 4,1% in Wroclaw to 45,5% in Ljubljana). Seropositivity / UBT rates vary from 13,9% in Ljubljana to 49% in Latvia. The eradication rates are from 88,2% in Dublin to 96,9% in Ljubljana. The use of all three treatment schemes showed encouraging eradication and adherence rates, whereas the incidence of adverse events due to this therapy was within the acceptable range. No serious adverse events have been reported so far. The differences among study sites are in the organisation of invitations, educational campaigns and dissemination activities as well as in the time when study was launched in a certain country.

Conclusion

The screen and treat application study is organised in a way as an organised cancer screening program. Careful study planning: legal, financial, technical, organisational aspect and public awareness campains should be implemented before official lounch of the study.Central data capture system is necessary to implement quality control monitoring. Education and public awareness campaign to increase the participation rate are of crucial importance.

Clinical Case Summary

Bouveret syndrome is a rare type of ileus caused by the impaction of large gallstones that pass through a cholecystoenteric fistula in the duodenum.Although endoscopic treatment is preferable over surgery for patients with Bouveret,1 some difficulties in endoscopic procedures must be overcome.2 Herein, we describe the usefulness of combined endoscopic procedures of electrohydraulic lithotripsy (EHL) and new technique by using the guide wire as a snare (Figure1).72 years old female patient known chronic liver disease and splenomegaly came to the emergency department by progressive abdominal pain, persistent vomiting, and weight loss two months ago. Upper Endoscopy was arranged next day and showed hugely dilated stomach with remnant food (signs of Gastric outlet obstruction) down to large stone at second part of duodenum totally obstructing lumen and a fistulous opening. MRCP was done and revealed: dilated Common Bile Duct about 10 mm down to its lower with extensive air in the biliary tree, dilated IHBRs with extensive pneumobilia, collapsed thick-walled gall bladder with air inside and large 35x55 mm impacted stone in the second part of the duodenum. An attempt using Biliary Electrohydraulic lithotripsy (EHL) was done, EHL over 3 hours was with minimal effect as the stone was hard and decreased the stone size to about 4 cm but it is still lodged in the angle, and we couldn’t grasp it by snare.We used Boston scientific guidewire 0.035 to create an open snare which overlapped the stone in its place then gradually pulled to the stomach. Over another 4 hours we used EHL and Lithotripsy stone extractor to destroy the stone into small fragments less than 1 cm.The stone was destroyed. The duodenum was reevaluated and circumferential ulcerations was noted with complete healing of fistula. The patient started oral intake 24 hours after the procedure with no abdominal pain or vomiting. Long term follow up of the patient showed marked weight gain with no adverse effects.

References

1. Cappell MS, Davis M. Characterization of Bouveret’s syndrome: A comprehensive review of 128 cases. A m J G a s t r o e n t e r o l 2006;
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2. Caldwell KM, Lee SJ, Leggett PL, Bajwa KS, Mehta SS, Shah SK. Bouveret syndrome: Current management strategies. C l i n E x p
69–75.