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Introduction Quadruple concomitant non-bismuth therapy has recently become the most widely prescribed first-line treatment for Helicobacter pylori infection in Spain. Whether optimised conventional triple therapy can achieve comparable efficacy rates remains to be seen. Materials and methods Retrospective study comparing the efficacy of triple and quadruple concomitant therapy, and sub-analysis following administration of both for 10 days with esomeprazole 40 mg/12 h. Results A first-line therapy was administered to 657 patients from 1st January 2012 to 31st December 2014. Quadruple therapy (n = 371) showed higher efficacy than triple therapy (n = 248) for both intention-to-treat (85.9% vs. 65.7%; P P P = .003) and per protocol analysis (92.5% vs.74.6%; P = .002). Conclusions Quadruple concomitant therapy with high dose proton pump inhibitor (PPI) for 10 days achieves a significantly higher eradication outcome than optimised triple therapy, with rates of over 90% when the PPI prescribed is esomeprazole 40 mg/12 h.

Resumen Introduccion Recientemente la cuadruple terapia concomitante sin bismuto se ha postulado como tratamiento de primera linea para la infeccion por Helicobacter pylori en Espana. Se desconoce si la optimizacion de la triple terapia clasica puede incrementar su efectividad hasta limites aceptables. Material y metodos Estudio retrospectivo que compara la eficacia de la triple terapia con la cuadruple concomitante realizando posteriormente un subanalisis cuando ambas se administran durante 10 dias empleando esomeprazol 40 mg/12 h. Resultados Desde el 1 de enero de 2012 hasta el 31 de diciembre de 2014 recibieron al menos una primera linea de tratamiento 657 pacientes. La cuadruple combinacion (n = 371) presento una eficacia superior a la de la triple terapia clasica (n = 248) tanto «por intencion de tratar» (85,9% vs. 65,5%; p = 0,003) como «por protocolo» (92,5% vs. 74,6%; p = 0,002). Conclusiones La terapia cuadruple concomitante con dosis altas de IBP durante 10 dias consigue tasas de erradicacion significativamente superiores a las obtenidos con la triple terapia optimizada y superiores al 90% cuando se utiliza esomeprazol 40 mg/12 h.

Introduction Alteration of mismatch repair system protein expression detected by immunohistochemistry (IHQ) in tumoural tissue is a useful technique for Lynch Syndrome (LS) screening. A recent review proposes LS screening through immunohistochemical study not only in all diagnosed cases of colorectal cancer (CRC) but also in advanced adenomas, especially in young patients. Objective To assess the prevalence of altered IHQ carried out in all adenomas with high-grade dysplasia (HGD) diagnosed in our community in 2011, as well as the variables associated with this alteration. Methods We included all the cases of adenomatous polyps with HGD diagnosed in the three public pathology laboratories of Navarre during 2011 and performed a statistical study to assess the association between different patient and lesion characteristics and altered IHQ results. Results A total of 213 colonic adenomas with HGD were diagnosed, and 26 (12.2%) cases were excluded from the final analysis (2 known LS, 22 without IHQ study and 2 with inconclusive IHQ studies). The final number of adenomas included was 187. Pathologic results were found in 10 cases (5.35%)–6 cases in MLH1 and PMS2, 2 cases in PMS2, 1 case in MSH6 and 1 case in MSH2 and MSH6. The factors showing a statistically significant association with the presence of abnormal proteins were the synchronous presence of CRC, the presence of only one advanced adenoma, proximal location of HGD and age Conclusions The percentage of pathologic nuclear expression found in IHQ is high. Consequently, screening of all diagnosed HGD could be indicated, especially in young patients, with a single AA and proximal HGD.

Resumen Introduccion La alteracion en la expresion nuclear de proteinas de los genes reparadores del ADN valorada mediante inmunohistoquimica (IHQ) en el tejido tumoral es una tecnica util como cribado de sindrome de Lynch (SL). Una revision reciente propone realizar este cribado no solo sobre todos los canceres colorrectales (CCR) diagnosticados, sino tambien sobre adenomas avanzados (AA), especialmente en pacientes jovenes. Objetivo Evaluacion de la prevalencia de IHQ alterada realizada sobre todos los adenomas con displasia de alto grado (DAG) diagnosticados en nuestra comunidad durante 2011, y descripcion de las variables asociadas a su alteracion. Metodos Se incluyeron todos los casos de polipos adenomatosos con DAG diagnosticados desde los 3 laboratorios de anatomia patologica publicos de Navarra durante el ano 2011, y se realizo un estudio estadistico para medir la asociacion de diferentes variables, tanto de los pacientes como de las lesiones con la presencia de IHQ alterada. Resultados Se diagnosticaron 213 adenomas de colon con DAG, excluyendose del analisis posterior 26 (12,2%) casos (2 SL ya diagnosticados, 22 casos sin estudio IHQ y 2 casos con IHQ no valorable), siendo el numero final 187. Se encontraron hallazgos patologicos en 10 casos, suponiendo el 5,35%: 6 casos en MLH1 y PMS2, 2 casos en PMS2, un caso en MSH6 y un caso en MSH2 y MSH6. La presencia sincronica de CCR, la presencia de un unico AA, la localizacion proximal de la DAG y la edad Conclusiones El porcentaje de expresion nuclear patologica hallado en la IHQ es elevado, por lo que podria estar indicado realizar screening de rutina con IHQ en todas las DAG diagnosticadas, especialmente en pacientes jovenes, con un unico AA y con DAG proximal.

Background and objective In a previous study we found that the classical triple therapy for Helicobacter pylori (H. pylori) had low efficacy (under 70%) in our area. After this finding, in mid 2012 quadruple concomitant therapy started to be prescribed in our hospital. The aim of the present study is to compare the efficacy of classical triple therapy and quadruple concomitant therapy without bismuth. Materials and methods Observational retrospective study of prescribed treatments between 1st January 2012 and 5th May 2014 and their efficacy. Results During the study period 510 patients were prescribed a first line therapy; in 179 cases (35.1%) the combination amoxiciline + clarithromicine + PPI was prescribed during 7–14 days, and 298 patients (58.4%) were treated with amoxicillin + clarithromycin + metronidazole + PPI for 10 days. The quadruple concomitant therapy had a higher efficacy than the classical triple therapy, both in an “intention to treat” (84.8% vs. 65.7%, P = .001) and “per protocol” (86.9% vs. 67.2%, P = .001) analysis. Triple therapy had a higher efficacy when it was prescribed for 10 days compared to 7 days (77.9% vs. 56.5%, P = .005 per “intention to treat” and 77.9% vs. 58.5%, P = .011 “per protocol”). When quadruple concomitant therapy was compared with classical triple therapy prescribed over 10 days no significant differences were found. Conclusions In our setting, quadruple concomitant therapy without bismuth has a high efficacy as first line therapy for H. pylori eradication, with much better results than classical triple therapy in the way that it is most widely prescribed (short courses of 7-day with a single dose of omeprazole).

Resumen Fundamento y objetivo Tras constatar que en nuestro medio la triple terapia clasica presentaba una eficacia suboptima en la erradicacion del Helicobacter pylori (H. pylori) , a mediados de 2012 decidimos implantar la cuadruple terapia concomitante sin bismuto. El objetivo de este estudio es comparar la eficacia de ambas pautas. Material y metodos Estudio retrospectivo observacional de las pautas erradicadoras administradas entre el 1 de enero de 2012 y el 5 de mayo de 2014, asi como su eficacia. Resultados En el periodo de estudio 510 pacientes recibieron al menos una primera linea de tratamiento que en 179 casos (35,1%) consistio en amoxicilina + claritromicina + IBP durante 7-14 dias, y en 298 (58,4%) en la combinacion amoxicilina + claritromicina + metronidazol + IBP 10 dias. La pauta cuadruple concomitante fue mas eficaz que la combinacion clasica, tanto «por intencion de tratar» (84,8 vs. 65,7%; p = 0,001) como «por protocolo» (86,9 vs. 67,2%; p = 0,001). La triple terapia fue mas eficaz cuando se empleaba en pautas de 10 dias que de 7 (77,9 vs. 56,5%; p: 0,005 por «intencion de tratar» y 77,9 vs. 58,5%; p: 0,011 por «protocolo»). Al comparar la eficacia de la cuadruple terapia con la triple administrada 10 dias no se encontraron diferencias significativas. Conclusiones En nuestro medio, la cuadruple terapia concomitante sin bismuto presenta una elevada eficacia como primera linea de tratamiento para la erradicacion del H. pylori , superando ampliamente la de la triple terapia en la forma en que esta viene administrandose mayoritariamente (pautas cortas de 7 dias).

Resumen Introduccion se discute la necesidad de efectuar sistematicamente una segunda gastroscopia de control tras el diagnostico inicial de una ulcera gastrica benigna. Metodo revisamos 226 casos consecutivos de ulcera gastrica. Analizamos la sensibilidad (S), la especificidad (E), el valor predictivo positivo y negativo (VPP, VPN) y la precision de la primera exploracion: gastroscopia con biopsias, de modo global y segun la experiencia del primer explorador (medico de plantilla o MIR). Comparamos la precision diagnostica entre la primera y la segunda endoscopia. Calculamos el numero necesario de segundas exploraciones (NNE) para diagnosticar un nuevo caso de ulcera maligna y su coste, tanto global como segun la experiencia del explorador. Resultados registramos 178 (79%) ulceras benignas y 48 (21%) malignas. La primera exploracion fue efectuada por un medico de plantilla (74%) y MIR (26%): S 87,2%, E 100%, VPP 100%, VPN 96,7% y precision 96,7%. La precision del medico de plantilla fue superior (98,2%) a la del MIR (94,8%) (p=0,18). La segunda exploracion de control tuvo una precision del 100%, mejorando significativamente a la primera (p=0,035) y diagnosticando 3 nuevos linfomas MALT y 3 carcinomas tratados con intencion curativa. El NNE y el coste de un nuevo diagnostico de lesion maligna fueron los siguientes: global, 37,3 (4.675 euros); medico de plantilla, 55,2 (6.845 euros), y MIR, 19,3 (2.393 euros). Conclusiones la primera exploracion obtuvo una elevada precision diagnostica, ligeramente menor para los MIR. La segunda endoscopia de control mejora significativamente los resultados, confirmando su beneficio clinico al diagnosticar lesiones malignas potencialmente curables. El coste medio de cada nuevo diagnostico de malignidad ascendio a 4.675 euros, siendo 3 veces inferior si la primera exploracion la efectua un medico con menos experiencia.

Resumen Objetivo Analizar la presencia de posibles rasgos diferenciales de la hemorragia digestiva alta (HDA) por lesion de Dieulafoy (LD), comparandola con el sangrado por ulcera gastroduodenal. Material y metodos Evaluamos los parametros referentes a las caracteristicas de los pacientes, de la hemorragia y de la gravedad clinica en 31 casos de hemorragia por LD y 31 por ulcera gastroduodenal. Se efectuo un analisis comparativo univarinate y multivariante entre ambos grupos. Resultados El indice de comorbilidad fue del 80% en LD y del 42% en la ulcera ( odds ratio [OR] = 5,54; intervalo de confianza del 95%, 1,5-20,7; p Conclusiones En la LD, la localizacion gastrica y el sangrado activo son hallazgos mas frecuentes que en el grupo ulceroso. El diagnostico de LD es mas dificil, ya que requiere un mayor numero de gastroscopias. La gravedad inicial de la hemorragia y el exito del tratamiento endoscopico sonsimilares en ambos grupos. La mayor mortalidad encontrada en las LD podria explicarse por la mayor comorbilidad de estos pacientes, con una peor tolerancia al sangrado.

Quadruple concomitant non-bismuth therapy has recently become the most widely prescribed first-line treatment for Helicobacter pylori infection in Spain. Whether optimized conventional triple therapy can achieve comparable efficacy rates remains to be seen.Retrospective study comparing the efficacy of triple and quadruple concomitant therapy, and sub-analysis following administration of both for 10 days with esomeprazole 40mg/12h.A first-line therapy was administered to 657 patients from 1st January 2012 to 31st December 2014. Quadruple therapy (n=371) showed higher efficacy than triple therapy (n=248) for both intention-to-treat (85.9% vs. 65.7%; P.001) and per protocol analysis (92.5% vs. 68.4%; P.001). When both therapies included esomeprazole 40mg/12h administered for 10 days, quadruple concomitant therapy (n=108) also had higher efficacy than triple therapy (n=76) for intention-to-treat (90.7% vs. 73.6%; P=.003) and per protocol analysis (92.5% vs.74.6%; P=.002).Quadruple concomitant therapy with high dose proton pump inhibitor (PPI) for 10 days achieves a significantly higher eradication outcome than optimized triple therapy, with rates of over 90% when the PPI prescribed is esomeprazole 40mg/12h.

To analyze the possible differential features of upper gastrointestinal (GI) bleeding due to Dieulafoy's lesion (DL) compared with bleeding due to gastroduodenal ulcer.We evaluated variables associated with patient characteristics, hemorrhagic characteristics and clinical severity in 31 cases of bleeding secondary to DL and 31 cases of gastroduodenal ulcer bleeding. Univariate and multivariate statistical analysis were performed.The comorbidity rate was 80% in the DL group and 42% in the ulcer group (OR = 5.54; 95%CI, 1.5-20.7; p0.0004). Lesion location was gastric in 87% of DL versus 39% of ulcers (OR = 10.7; 95%CI, 2.6-47.6; p0.0003). More than one gastroscopy was required for diagnosis in 30% of DL vs. 3.2% of ulcers (OR = 12.9; 95%CI, 1.4-291; p0.01). Endoscopic treatment was required in 97% of DL and 39% of ulcers (OR = 47.5; 95%CI, 5.5-106.1; p0.0001). Active bleeding during endoscopy was registered in 81% of DL and in 29% of ulcers (OR = 10.2; 95%CI, 2.7-40.3; p0.0005). The remaining variables analyzed showed no significant differences. The mortality rate was 9.7% in the DL group and 3.2% in the ulcer group (p = NS). Multivariate analysis showed that gastric location (p0.01), active bleeding (p0.01), and comorbidity (p0.02) were more frequent in DL.Active bleeding and gastric location of the lesion were more frequent in the DL group than in the ulcer group. Diagnosis of DL is difficult, requiring a greater number of gastroscopies. Initial hemorrhage severity and the success rate of endoscopic treatment were similar in the two groups. The higher mortality found in DL can be explained by the greater comorbidity in these patients, with a worse bleeding tolerance.

We analyzed the need to routinely perform a second gastroscopy after an initial diagnosis of benign gastric ulcer.A total of 226 consecutive cases of gastric ulcer were reviewed. Sensitivity (S), specificity (Sp), positive and negative predictive value (PPV and NPV) and the accuracy of the initial gastroscopy plus biopsy were analyzed, both overall and according to the initial endoscopist's experience (attending or resident physician). The diagnostic accuracy of the initial and second-look gastroscopies was compared. The number of second endoscopies required to diagnose a new case of malignant gastric ulcer and their cost was calculated, both overall and according to the endoscopist's experience.There were 178 benign ulcers (79%) and 48 malignant ulcers (21%). The initial gastroscopy (S: 87.2%; Sp: 100%; PPV: 100%; PNV: 96.7%; accuracy: 96.7%) was performed by an attending physician in 74% of the patients and by a resident physician in the remaining 26%. Diagnostic accuracy was higher for attending physicians than for residents (98.2% vs. 94.8%; p=0.18). The accuracy of second-look endoscopy was 100%, with a significant improvement when compared with the initial procedure (p=0.035). Three new cases of MALT lymphoma and three new cases of gastric adenocarcinoma were diagnosed and could be treated with curative intent. The number of second gastroscopies required to diagnose a new case of malignant gastric ulcer and their economic cost was: 37.3 (4,675 Euros) for the whole group, 55.2 (6,845 Euros) for attending physicians and 19.3 (2,393 Euros) for residents.Initial gastroscopy showed high diagnostic accuracy, which was slightly lower when performed by resident physicians. Second-look gastroscopy significantly improved the results, confirming the clinical benefit of this procedure in diagnosing potentially curable malignant lesions. The mean cost of each new diagnosis of malignancy was 4,675 Euros, which was three times lower if the initial gastroscopy was performed by a less experienced endoscopist.

AIM: To discuss the feasibility of single session endoscopic ultrasonography (EUS) to discuss and endoscopic retrograde cholangiopancreatography (ERCP) execution. METHODS: Retrospective endoscopic and anesthetic outcome comparison of performing both EUS and ERCP in a single endoscopic session (Group I) versus performing each procedure in two different sessions (Group II) was made. The following variables were evaluated: epidemiological variables, American Society of Anesthesiologists Physical Status Classification (ASA) level, procedural time, propofol dose, anesthetic complications, endoscopic complications and diagnostic yield, and therapeutic procedures on both groups. T-student, Chi-Square and Fisher test were used for comparison. RESULTS: We included 39 patients in Group I (mean age: 69.85 ± 9.25; 27 men) and 46 in Group II (mean age: 67.46 ± 12.57; 25 men). Procedural time did not differ significantly between both groups (Group Ivs Group II: 93 ± 32.78 vs 98.98 ± 38.17; P >0.05) but the dose of propofol differed (Group I vs Group II: 322.28 ± 250.54 mg vs 516.96 ± 289.06 mg; P = 0.001). Three patients had normal findings on both explorations. Three anesthetic complications [O2 desaturation (2), broncoaspiration (1)] and 9 endoscopic complications [pancreatitis (6), bleeding (1), perforation (1), cholangitis (1)] occurred without significant differences between both groups (P > 0.05). We did not find any significant difference regarding age, sex, ASA scale level, diagnostic yield or therapeutic maneuvers between both groups. CONCLUSION: The performance of EUS and ERCP in a single session offers a similar diagnostic and therapeutic yield, does not entail a higher complication risk and requires a significantly smaller dose of propofol for sedation compared with performing each exploration in a different session.

ObjectiveThe best approach for Helicobacter pylori management remains unclear. An audit process is essential to ensure clinical practice is aligned with best standards of care.DesignInternational multicentre prospective non-interventional registry starting in 2013 aimed to evaluate the decisions and outcomes in H. pylori management by European gastroenterologists. Patients were registered in an e-CRF by AEG-REDCap. Variables included demographics, previous eradication attempts, prescribed treatment, adverse events and outcomes. Data monitoring was performed to ensure data quality. Time-trend and geographical analyses were performed.Results30 394 patients from 27 European countries were evaluated and 21 533 (78%) first-line empirical H. pylori treatments were included for analysis. Pretreatment resistance rates were 23% to clarithromycin, 32% to metronidazole and 13% to both. Triple therapy with amoxicillin and clarithromycin was most commonly prescribed (39%), achieving 81.5% modified intention-to-treat eradication rate. Over 90% eradication was obtained only with 10-day bismuth quadruple or 14-day concomitant treatments. Longer treatment duration, higher acid inhibition and compliance were associated with higher eradication rates. Time-trend analysis showed a region-dependent shift in prescriptions including abandoning triple therapies, using higher acid-inhibition and longer treatments, which was associated with an overall effectiveness increase (84%–90%).ConclusionManagement of H. pylori infection by European gastroenterologists is heterogeneous, suboptimal and discrepant with current recommendations. Only quadruple therapies lasting at least 10 days are able to achieve over 90% eradication rates. European recommendations are being slowly and heterogeneously incorporated into routine clinical practice, which was associated with a corresponding increase in effectiveness.