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

This study investigates the dynamic mechanisms by which Helicobacter pylori (Hp) eradication therapy influences gut microbiota and metabolome. Current rescue regimens, specifically high-dose dual therapy (HDDT) combining vonoprazan (VPZ) and amoxicillin, lack thorough exploration regarding their effects on gut microbiota and host metabolism. Additionally, the timing of probiotic intervention remains poorly understood.

Aims & Methods

Utilizing multi-omics approaches, this study aims to clarify how probiotics administered at different times influence gut microbial composition, metabolic profiles, and their interaction in patients undergoing Hp rescue therapy, thereby providing a theoretical foundation for enhancing Hp eradication strategies through microbial-metabolic modulation.
From January to December 2024, 120 patients undergoing Hp rescue therapy were randomized into four groups (A–D). Group A received VPZ 20 mg bid + amoxicillin 0.75 g qid for two weeks, followed by Bacillus subtilis dual-strain enteric-coated capsules (2 tablets tid) for two weeks. Group B received VPZ 20 mg bid + amoxicillin 0.75 g qid + Bacillus subtilis capsules (2 tablets tid) for two weeks. Group C was treated with VPZ 20 mg bid + amoxicillin 0.75 g tid for two weeks. Group D received Bacillus subtilis capsules (2 tablets tid) for two weeks, followed by VPZ 20 mg bid + amoxicillin 0.75 g qid for two weeks. Twenty-five Hp-negative individuals served as controls. Fecal samples were collected at baseline, 4 weeks, and 12 weeks post-treatment. Gut microbiota diversity and composition were analyzed through metagenomic sequencing; untargeted metabolomics was conducted using LC-MS; and small intestinal bacterial overgrowth was assessed via hydrogen-methane breath testing.

Results

1) No significant differences in gut microbiota alpha (Shannon index) or beta diversity (Bray-Curtis) were observed between H. pylori (Hp)-infected and uninfected groups (P=0.65). Hp-positive individuals exhibited elevated Collinsella aerofaciens and reduced Roseburia faecis and Agathobacter spp. (P<0.05). Metabolomic analysis identified 886 differentially abundant metabolites (P<0.05, VIP>1, FC≠1) enriched in 45 KEGG pathways, with key biomarkers including deoxyribose 5-phosphate and 4-vinylcyclohexene dioxide (P<0.01). The prevalence of SIBO was higher in patients with H. pylori infection than in those without infection (P<0.05). 2) Post-treatment alpha/beta diversity remained stable across groups A–D (P>0.05). Metabolic pathway profiles diverged: Group A emphasized phenylpropanoid biosynthesis; Group B showed cytochrome P450 drug metabolism; Group C featured sphingolipid metabolism and necroptosis; Group D upregulated cofactor/flavonoid biosynthesis. No significant SIBO changes occurred post-treatment in any group. 3) At week 4, beta diversity separation (P=0.009) was driven by Bacillota, Blautia, Ruminococcus sp., and Phocaeicola sp., with metabolites like Fahfa(3:0/24:1) linked to inflammation. By week 12, Groups B and C displayed distinct alpha (Sobs) and beta diversity (P=0.011), distinguished by Escherichia coli and Faecalibacterium prausnitzii. Group C exhibited upregulated anti-inflammatory metabolites (e.g., luteolin) and mucosal repair markers. 4) Multi-omics integration revealed early metabolic compensation at week 4 (Bifidobacterium-mediated amino acid/bile acid homeostasis) and late-stage recovery (week 12) marked by Pseudomonadota proliferation (E. coli) and Faecalibacterium grausatizii-associated sulfated steroids/phosphosphingolipids, supporting immune regulation and mucosal repair.

Conclusion

Probiotic-augmented HDDT has minimal impact on gut microbiota diversity and small intestinal bacterial overgrowth but significantly enhances the probiotic-microbiota-metabolite axis, particularly in sustaining anti-inflammatory metabolites and immune regulation.

Disclosure

The authors have no conflicts of interest to declare.

Introduction

Endoscopic drainage is standard of care in malignant biliary obstruction (MBO).

Aims & Methods

The aim of this study was to investigate efficacy of biliary stenting in providing access to systemic chemotherapy. Patients with biliary obstruction (bilirubin >2.5 mg/dl) caused by unresectable biliary or pancreatic cancer were retrospectively analyzed with respect to use of chemotherapy and survival. Laboratory data were analyzed at baseline, 7-10 and 28-35 days following biliary stenting.

Results

Patients with MBO (n=78) were allocated into one of three groups according to bilirubin level [mg/dl] 2.5 – 5.99 (group 1), 6.0 - 15.0 (group 2) and >15 (group 3). On first blood testing mean bilirubin declines from baseline in respective groups were: 1.19 (29.5%), 3.77 (38.5%) and 7.1 (27.3%), and on second measurement 1.61 (40%), 5.69 (58.2%) and 13.0 (50%). Chemotherapy was applied in 28 (35.8%) patients, less frequently in group 3 than in group 1 (31.2% vs 44.0%; p =0.07) and group 2 (vs 38.1%; p =0.06). Mean survival time was 4.8 ±2.8 months and was significantly shorter in group 3 as compared to group 2 (3.8 ±2.0 vs 6.2 ±3.9 months; p =0.02) and to group 1 (vs 5.4 ±2.7 months; p =0.03).

Conclusion

In two-thirds of patients with MBO endoscopic biliary drainage does not grant access to chemotherapy. Use of chemotherapy and survival time are significantly higher in patients with bilirubin level below 15 mg/dl as compared to those with greater bilirubinemia, but in patients with bilirubin level below 6 mg/dl the biliary drainage is minimally effective.

Disclosure

No.