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Background: The high incidence rate of peristomal skin complications (PSCs) indicates that current ostomy products are not meeting the needs of ostomates. Aims: To assess how switching to a novel barrier ring affects the peristomal skin health of people with an ileostomy and the usability of the novel barrier ring. Methods: Participants (aged ≥18 years) with an ileostomy for 3 months or more wore a novel barrier ring with their typical ostomy appliances for a duration of 4 weeks. The Ostomy Skin Tool (OST) was used by trained nurses to assess skin condition at time T=0 and time T=4 weeks. The participants' experience with using the novel barrier ring was also evaluated, using a questionnaire at time T=4 weeks. Findings: Among 19 participants, switching to the novel barrier ring resulted in a statistically significant improvement in peristomal skin health. The average OST score started at 6.21±3.63 (SD) at time T=0 and decreased to 3.63±3.56 at time T=4 weeks (pConclusion: The novel barrier ring assessed shows high potential to improve peristomal skin health, even for patients who already use market-standard seals. High scores were received for usability and comfort, and the potential of the novel barrier ring to reduce leaks and increase longevity of ostomy systems was realised.

This study reviews the safety and efficacy of treatment with vedolizumab for patients with inflammatory bowel disease across 9 Irish hospitals. It generates valuable and timely real-world data on treatment outcomes to add to the existing evidence base. Our population represents a refractory cohort with most patients previously exposed to at least one anti-TNFa agent and expressing an inflammatory phenotype. Results are reassuringly similar to larger international studies with additional insights into potential predictors of treatment response. This study further supports the safety and efficacy of vedolizumab in the treatment of inflammatory bowel disease. Key SummaryVedolizumab has growing real world data on its safety and efficacy in the treatment of IBD. Data on predictors of response are lacking. Studies such as VARSITY require new real-world data to help identify the place VDZ will occupy in the treatment algorithm for IBDThis study provides national Irish data on the safety and efficacy of VDZ in the treatment of IBD. It gives insight into various predictors of response for both UC and CD. It strengthens the available body of evidence on the use of VDZ and helps us determine its position on the treatment algorithm.

Introduction. Upper gastrointestinal (UGI) video capsule endoscopy (VCE) provides a possible alternative to conventional oesophago-gastro-duodenoscopy (OGD). In Ireland, the COVID-19 pandemic led to unprecedented change in endoscopy services, accelerating the need for UGI VCE to help reduce patient exposure but allow the continuation of endoscopy services. We report on using UGI VCE as an alternative to OGD throughout all phases of COVID-related endoscopy adjustments. Aims/Background. Prospective observational study to assess identification of relevant UGI anatomical landmarks on UGI VCE as defined in the British Society of Gastroenterology. Method. Inclusion criteria were: patients with dyspepsia under 40 years of age with no alarm symptoms; known cirrhosis for variceal screening; UGI bleeds with the Blatchford score ≤ 2 . A protocol for preparation and a series of positional movements were adapted for the procedure. Landmarks and pathology detection were evaluated by two independent endoscopists. Results. 127 UGI VCE was performed from June 2020 to December 2021, of which 22 required further evaluation with OGD. The most common indications were dyspepsia and abdominal pain, 71% and 19%, respectively. With the use of the dual-facing camera, clear views of the OGJ in 100% of cases, cardia 100%, fundus 97%, greater curve 99%, lesser curve 98%, incisura angularis 95%, antrum 95%, pylorus 94%, D1/bulb 83%, and D2 82% were obtained. The main findings at UGI VCE were reflux oesophagitis and gastritis, with normal mucosa observed in 48% of cases. Findings suggesting a neoplastic lesion at the OG junction were detected in 1 case. Conclusion. Since June 2020, 81% ( N = 103 ) of a selected cohort of patients referred for UGI endoscopy avoided invasive traditional endoscopy and were successfully managed by VCE, thus reducing endoscopy waiting lists. UGI VCE may serve as a clinical diagnostic tool, used alongside OGD in appropriate cases, to help improve patient services and care delivery.

Spore-based probiotics offer important advantages over other probiotics as they can survive the harsh gastric conditions of the stomach and bile salts in the small intestine, ultimately germinating in the digestive tract. A novel clinical trial in 11 ileostomy participants was conducted to directly investigate the presence and germination of the probiotic strain Bacillus subtilis DE111® in the small intestine. Three hours following ingestion of DE111®, B. subtilis spores (6.4 × 104 ± 1.3 × 105 CFU/g effluent dry weight) and vegetative cells (4.7 × 104 ± 1.1 × 105 CFU/g effluent dry weight) began to appear in the ileum effluent. Six hours after ingestion, spore concentration increased to 9.7 × 107 ± 8.1 × 107 CFU/g and remained constant to the final time point of 8 h. Vegetative cells reached a concentration of 7.3 × 107 ± 1.4 × 108 CFU/g at 7 h following ingestion. These results reveal orally ingested B. subtilis DE111® spores are able to remain viable during transit through the stomach and germinate in the small intestine of humans within 3 h of ingestion.

Aims At the peak of the Covid-19 pandemic in Ireland, many routine and surveillance endoscopies were deferred, with onlyurgent procedures prioritised. The PillCam ESO (Given Imaging Ltd., Yoqneam, Israel) is a non-invasive investigation, whichoffers an alternative method of evaluating the UGI tract for non-urgent referrals for endoscopy. A prospective study to assess if the PillCam ESO can identify important anatomical landmarks stated in the British Societyof Gastroenterology quality standards for upper gastrointestinal endoscopy and pathology in the Upper GI Tract. Methods Patients who fitted our inclusion criteria were prospectively invited to participate into our trial. The three main indications were 1;patients with dyspepsia less than 40 years of age with no red flag symptoms, 2;knowncirrhosis to screen for varices, 3;UGI bleeds with a low Blatchford score (≤2). A local protocol for ingestion and series of positional guidelines was developed for the procedure. Endoscopic landmarks, and pathology detection were evaluated by two independent endoscopists. Results 32 exams have been successfully performed from June 2020 to date without complications. The two frequentindications were dyspepsia (66 %) and abdominal pain (19 %). Metoclopramide was administered in 66 % of cases. Visualisation of the following major anatomical landmarks was achieved in 100 % of cases: Oesophagus, oesophageal-gastro junction, greater curve, pylorus. A full view of the cardia, fundus, lesser curve, incisura angularis and antrum was obtained in 97 %, 87 %, 93 %, 97 % and97 % of cases, respectively. D2 intubation was achieved in 90 % of cases. A normal exam was reported in 34 % of cases.Reflux oesophagitis and gastritis were the most common pathology detected. Adenocarcinoma of the OG junction wasdetected in 1 case. Conclusions The PillCam ESO achieves excellent views of the upper GI tract. In selective cases, it is a safe alternative togastroscopy which may help reduce gastroscopy waiting times.

Introduction This study evaluated corticosteroid and antibiotic prescribing during the first 12 months of first-line biologic therapy in patients with ulcerative colitis (UC) initiated on vedolizumab (VDZ) compared with patients initiated on anti-tumour necrosis factor-α (anti-TNF) agents. Methods A multicentre, retrospective observational study was conducted in six United Kingdom secondary care centres. Eligible consenting patients were aged ≥18 years at initiation, without primary fistulising disease or acute severe disease. Patients were matched for age, gender, Montreal classification of disease extent and steroid use at initiation. Results The study included 56 patients initiated on VDZ and 56 patients initiated on anti-TNF (table 1). During the overall 12 month post-initiation observation period, patients initiated on VDZ and anti-TNF were prescribed a median of 1.0 (interquartile range [IQR] 0.0–4.8) and 2.0 (IQR 0.0–7.8; Mann-Whitney U test P=0.16) courses of corticosteroids, respectively. During the post-initiation maintenance period (week 14 to month 12), 37% (95% confidence interval [CI] 24%–49%; n=52) of patients initiated on VDZ and 57% (95%CI 44%–70%; n=53; χ2P=0.039) of patients initiated on anti-TNF received at least one course of corticosteroids. During the overall 12 month post-initiation observation period, patients initiated on VDZ and anti-TNF were prescribed a median of 0 (range 0–4) and 0 (range 0–2; Mann-Whitney U test P=0.42) courses of antibiotics, respectively. During the post-initiation maintenance period, 11% (95%CI 3%–19%; n=56) of patients initiated on VDZ and 16% (95%CI 6%–26%; n=56; χ2 P=0.41) of patients initiated on anti-TNF received at least one course of antibiotics. Conclusions During the post-initiation maintenance period of first-line biologic therapy in patients with UC, patients initiated on VDZ were significantly less likely to be prescribed corticosteroids than matched patients initiated on anti-TNF agents. Numerically less patients on VDZ received antibiotics, however this did not reach significance.

Aim: Small bowel capsule retention is rare, with a rate of approximately 2%, defined as visible retention on plain film of abdomen (PFA) after 14 days. Currently, PFA is performed if the capsule is not seen to reach the large bowel during recording. Alternatively, for upper gastrointestinal (UGI) capsule studies, the risk of retention is determined if the capsule fails to reach the small bowel during recording. Given the similar physical specifications of the capsules (Medtronic) used, we considered whether 14-day PFA is no longer required for small bowel capsules not observed in the large bowel. Methods: The use of patency capsules in our lab allows careful selection of small bowel capsule studies to minimize the risk of retention. All PFAs performed over a five-year period were reviewed to determine if careful selection and use of patency negate the need for capsule retention PFA screening. Results: In total, 688 small-bowel capsules were performed during the study period, and 3.6% had prior patency capsules. Thirty-one PFAs with a query of capsule retention were performed during the study period on 28 patients. This included 15 females, and the median age was 53.5 years. None of the films demonstrated capsule retention. Conclusion: Our data suggest that 14-day PFA may no longer be required for small bowel capsules not seen to reach the large bowel. Advice regarding symptoms of capsule retention and precaution with magnetic resonance imaging, similar to current UGI capsule advice, may suffice. This may reduce the burden on radiology imaging slots and, in particular, eliminate unnecessary radiation exposure and repeat hospital attendance for patients.

Ten of the world's biggest rivers are located entirely within the Asian Monsoon region. They provide water, energy, and food for 1.7 billion people. To manage these critical resources, we need a better understanding of river discharge���how does it change over a long time? Are there common variation patterns among rivers? To answer these questions, we use information derived from tree rings to reconstruct average annual river discharge history at 62 gauges in 16 Asian countries. Our reconstruction reveals the riparian footprint of megadroughts and large volcanic eruptions over the past eight centuries. We show that simultaneous droughts and pluvials have often occurred at adjacent river basins in the past, because Asian rivers share common influences from the Pacific, Indian, and Atlantic Oceans. We also show how these oceanic teleconnections change over space and time. Our findings can inform big decisions made on water-dependent infrastructure, thus benefiting the riparian people of the Asian Monsoon region.

Summary Barrett’s esophagus (BE) is the main pathological precursor of esophageal adenocarcinoma (EAC). Progression to high-grade dysplasia (HGD) or EAC from nondysplastic BE (NDBE), low-grade dysplasia (LGD) and indefinite for dysplasia (IND) varies widely between population-based studies and specialized centers for many reasons, principally the rigor of the biopsy protocol and the accuracy of pathologic definition. In the Republic of Ireland, a multicenter prospective registry and bioresource (RIBBON) was established in 2011 involving six academic medical centers, and this paper represents the first report from this network. A detailed clinical, endoscopic and pathologic database registered 3,557 patients. BE was defined strictly by both endoscopic evidence of Barrett’s epithelium and the presence of specialized intestinal metaplasia (SIM). A prospective web-based database was used to gather information with initial and follow-up data abstracted by a data manager at each site. A total of 2,244 patients, 1,925 with no dysplasia, were included with complete follow-up. The median age at diagnosis was 60.5 with a 2.1:1 male to female ratio and a median follow-up time of 2.7 years (IQR 1.19–4.04), and 6609.25 person years. In this time period, 125 (5.57%) progressed to HGD/EAC, with 74 (3.3%) after 1 year of follow-up and 38 (1.69%) developed EAC, with 20 (0.89%) beyond 1 year. The overall incidence of HGD/EAC was 1.89% per year; 1.16% if the first year is excluded. The risk of progression to EAC alone overall was 0.57% per year, 0.31% excluding the first year, and 0.21% in the 1,925 patients who had SIM alone at diagnosis. Low-grade dysplasia (LGD) progressed to HGD/EAC in 31% of patients, a progression rate of 12.96% per year, 6.71% with the first year excluded. In a national collaboration of academic centers in Ireland, the progression rate for NDBE was similar to recent population studies. Almost one in two who progressed was evident within 1 year. Crucially, LGD diagnosed and confirmed by specialist gastrointestinal pathologists represents truly high-risk disease, highlighting the importance of expertise in diagnosis and management, and providing indirect support for ablative therapies in this context.

Background & Aims Enteropathy and small-intestinal ulcers are common adverse effects of nonsteroidal anti-inflammatory drugs such as acetylsalicylic acid (ASA). Safe, cytoprotective strategies are needed to reduce this risk. Specific bifidobacteria might have cytoprotective activities, but little is known about these effects in humans. We used serial video capsule endoscopy (VCE) to assess the efficacy of a specific Bifidobacterium strain in healthy volunteers exposed to ASA. Methods We performed a single-site, double-blind, parallel-group, proof-of-concept analysis of 75 heathy volunteers given ASA (300 mg) daily for 6 weeks, from July 31 through October 24, 2017. The participants were randomly assigned (1:1) to groups given oral capsules of Bifidobacterium breve (Bif195) (≥5 × 1010 colony-forming units) or placebo daily for 8 weeks. Small-intestinal damage was analyzed by serial VCE at 6 visits. The area under the curve (AUC) for intestinal damage (Lewis score) and the AUC value for ulcers were the primary and first-ranked secondary end points of the trial, respectively. Results Efficacy data were obtained from 35 participants given Bif195 and 31 given placebo. The AUC for Lewis score was significantly lower in the Bif195 group (3040 ± 1340 arbitrary units) than the placebo group (4351 ± 3195) (P = .0376). The AUC for ulcer number was significantly lower in the Bif195 group (50.4 ± 53.1 arbitrary units) than in the placebo group (75.2 ± 85.3 arbitrary units) (P = .0258). Twelve adverse events were reported from the Bif195 group and 20 from the placebo group. None of the events was determined to be related to Bif195 intake. Conclusions In a randomized, double-blind trial of healthy volunteers, we found oral Bif195 to safely reduce the risk of small-intestinal enteropathy caused by ASA. ClinicalTrials.gov no: NCT03228589.

The demand for endoscopic services is increasing rapidly, and this necessitates optimal efficiency in the endoscopy unit. Aim: To assess the efficiency of an endoscopy unit, concentrating in the delay pre-and post-procedure. Patients: Outpatient/day ward procedures. Methods: We examined the delay in endoscopic procedures between 19 and 30 May 2014. The procedure process was examined at three different stages: stage 1 is from when the ‘patients arrives to pre-procedure ward’ to ‘ready for procedure’; stage 2 is from ‘where the patient is ready and waiting to be called’ to ‘when the endoscopy procedure commences’; and stage 3 is from ‘when the ward is contacted to collect patient post procedure’ to ‘when the patient is discharged from the ward’. Results: The pathways for 238 endoscopic procedures were assessed. In total, 249 episodes of delay were documented. Stage 1 accounts for 28% of the delays; there is 1.1–1.6 hours of a delay per patient at this stage. Stage 2 accounts for 53% of the delays; there is a delay of 2.5–2.75 hours per patient at this stage. Stage 3 accounts for 19% of the delays; there is a delay of 1.75 – 2 hours per patient at this stage. Conclusion: Delays were a major factor affecting optimal use of available day ward/endoscopy resources. Significant delay can occur pre-and post-procedure. Strategies to reduce peri-procedural delays could have a favourable impact on day ward capacity and the volume of procedures performed in the endoscopy unit.

Background Helicobacter pylori is the major cause of chronic gastritis, and considered as a risk factor for peptic ulcer and gastric cancer. The H. pylori standard antibiotic therapy fails in about 25–30% of cases, particularly because of the increasing occurrence of resistance to antibiotics. The aim of the current study was to investigate whether the strain Lactobacillus reuteri DSM17648 which has been previously shown to reduce Helicobacter pylori load additionally improves gastrointestinal symptoms in H. pylori positive subjects when used in a 28 days supplementation. Methods In a single-blinded, placebo controlled study 24 H. pylori-positive adults (13 females, 11 males; median age: 43.5) with mild dyspepsia (mean GSRS score: 11.82) received placebo for 28 days followed by Pylopass™ containing the L. reuteri DSM 17648 (2 × 1010 cells per day) for the following 28 days. After 28 days of Pylopass™ supplementation the change in H. pylori load was measured by 13C urea breath test (13C-UBT) and the change in symptoms were determined by the Gastrointestinal Symptom Rating Scale (GSRS). In addition, blood assessments were conducted to measure the physiological changes relevant in terms of safety. Results After a 28-day supplementation phase with Pylopass™ there was a trend for reduction of H. pylori load in 62.5% of the subjects and for the overall GSRS scores in 66.7% of subjects. The overall GSRS scores from baseline to day 56 following all 24 subjects undergoing the placebo phase followed by the Pylopass™ phase was significantly decreased (p = 0.005). The mean 13C-UBT δ value decreased by 22.5% during the Pylopass™ supplementation phase (− 3.14), while the mean 13C-UBT δ increased by 37.3% (+ 3.79) in the placebo phase. No side effects were reported in either study phase. Conclusion The results demonstrated that L. reuteri DSM17648 has the potential to suppress H. pylori infection, and may lead to an improvement of H. pylori-associated gastro intestinal symptoms. Further studies with adequate power should be performed. Trial registration Clinicaltrials.gov: NCT02051348 (January 30, 2014).

Irish eradication rates for Helicobacter pylori are decreasing and there is an increase in the prevalence of antibiotic-resistant bacteria. These trends call into question current management strategies.To establish an Irish Helicobacter pylori Working Group (IHPWG) to assess, revise and tailor current available recommendations.Experts in the areas of gastroenterology and microbiology were invited to join the IHPWG. Questions of relevance to diagnosis, first-line and rescue therapy were developed using the PICO system. A literature search was performed. The 'Grading of Recommendations Assessment, Development and Evaluation' approach was then used to rate the quality of available evidence and grade the resulting recommendations.Key resultant IHPWG statements (S), the strength of recommendation and quality of evidence include S8: standard triple therapy for 7 days' duration can no longer be recommended (strong and moderate). S9: 14 days of clarithromycin-based triple therapy with a high-dose proton pump inhibitor (PPI) is recommended as first-line therapy. Bismuth quadruple therapy for 14 days is an alternative if available (strong and moderate). S12: second-line therapy depends on the first-line treatment and should not be the same treatment. The options are (a) 14 days of levofloxacin-based therapy with high-dose PPI, (b) 14 days of clarithromycin-based triple therapy with high-dose PPI or (c) bismuth quadruple therapy for 14 days (strong and moderate). S13: culture and antimicrobial susceptibility testing should be performed following two treatment failures (weak and low/very low).These recommendations are intended to provide the most relevant current best-practice guidelines for the management of H. pylori infection in adults in Ireland.

In the present study, structural changes in the milk protein α-lactalbumin (α-LA) and its proteolysis were investigated for the potential formation of protein–fatty acid complexes during in vivo gastric digestion. Capsule endoscopy allowed visualisation of the digestion of the test drinks, with nasogastric tubes allowing sampling of the gastric contents. A total of ten healthy volunteers had nasogastric tubes inserted into the stomach and ingested test drinks containing 50 g/l of sucrose and 25 g/l of α-LA with and without 4 g/l of oleic acid (OA). The samples of gastric contents were collected for analysis at 3 min intervals. The results revealed a rapid decrease in the pH of the stomach of the subjects. The fasting pH of 2·31 (sd 1·19) increased to a pH maxima of pH 6·54 (sd 0·29) after ingestion, with a subsequent decrease to pH 2·22 (sd 1·91) after 21 min (n 8). Fluorescence spectroscopy and Fourier transform IR spectroscopy revealed partial protein unfolding, coinciding with the decrease in pH below the isoelectric point of α-LA. The activity of pepsin in the fasting state was found to be 39 (sd 12) units/ml of gastric juice. Rapid digestion of the protein occurred: after 15 min, no native protein was detected using SDS–PAGE; HPLC revealed the presence of small amounts of native protein after 24 min of gastric digestion. Mirocam® capsule endoscopy imaging and video clips (see the online supplementary material) revealed that gastric peristalsis resulted in a heterogeneous mixture during gastric digestion. Unfolding of α-LA was observed during gastric transit; however, there was no evidence of a cytotoxic complex being formed between α-LA and OA.

Experimental and clinical studies suggest an association between small intestinal bacterial overgrowth (SIBO) and nonalcoholic steatohepatitis (NASH). Liver injury and fibrosis could be related to exposure to bacterial products of intestinal origin and, most notably, endotoxin, including lipopolysaccharide (LPS). To compare the prevalence of SIBO and its relationships to LPS receptor levels and systemic cytokines in NASH patients and healthy control subjects. Eighteen NASH patients (eight males) and 16 age-matched and gender-matched healthy volunteers were studied. SIBO was assessed by the lactulose breath hydrogen test (LHBT), plasma lipopolysaccharide binding protein (LBP) levels by ELISA, and expression (as a percentage) of TLR-2 and 4 on CD14-positive cells by flow cytometry. Pro-inflammatory cytokines (IL-1β, IL-6, IL-8, and TNF-α) were measured in plasma. SIBO was more common in NASH patients than control subjects (77.78% vs. 31.25%; P

6-Thioguanine has been used as an alternative immunomodulator in the treatment of inflammatory bowel disease but data on its efficacy and safety are limited. The aim of this study was to analyse our experience of the efficacy and safety of 6-thioguanine in inflammatory bowel disease.Patients attending the inflammatory bowel disease clinic who were started on 6-thioguanine therapy were included in this prospective observational study. Indications for initiating 6-thioguanine therapy and other related clinical, pharmacological and laboratory parameters prior to and during therapy were recorded to determine the efficacy and safety of 6-thioguanine.A total of 40 patients were treated with 6-thioguanine, 28 with Crohn's disease, 10 with ulcerative colitis and 2 with indeterminate colitis, at a fixed daily dose of 40 mg and continued for a median duration of 34 weeks (range 2-90 weeks). The indications for 6-thioguanine therapy included previous clinical resistance to thiopurine analogues (n=21), intolerance to thiopurine analogues (n=8) and de novo 6-thioguanine use in steroid refractory disease (n=11). Disease remission was reached in 44%, 73% and 89% of these patient groups at 3, 6 and 12 months, respectively. Inflammatory markers and steroid use were significantly lower during 6-thioguanine therapy compared with in the period before therapy. Therapy was discontinued in 13 patients (33%), mainly because of thrombocytopenia and associated hepatotoxicity.6-Thioguanine is a useful addition to treatment in inflammatory bowel disease but the frequent occurrence of hepatotoxicity limits its routine use.

The genomic contents of Helicobacter pylori strain C1 from a patient with gastric cancer and strain 98587 from a patient with duodenal ulcer disease were compared using a rapid subtractive hybridisation approach. A total of 11 tester-specific sequences representing gene specificity, DNA rearrangement and sequence variation were identified. This included two novel sequences, clone P32 and clone F5, which have no significant homologue in the database. H. pylori strains positive for clone P32 were less prevalent in patients with gastric intestinal metaplasia (12.5%) than in duodenal ulcer (39.1%) (p = 0.036), or chronic gastritis (38.1%) (p = 0.036). The results suggest that H. pylori clone P32 is potentially a useful marker for distinguishing intestinal metaplasia associated strains from others. 2005 Federation of European Microbiological Societies. Published by Elsevier B.V. All rights reserved.

Self-expanding metal stents have been used in the management of colorectal obstruction as an alternative to emergency surgery. Our aim was to systematically review the efficacy and safety of these stents in the setting of malignant colorectal obstruction.Both English and foreign language reports were identified from Medline, Embase, Cancerlit, Science Citation Index, Cochrane Library, and proceedings of relevant meetings. Data were collected on technical success, clinical success, and safety parameters.Fifty-four studies reported the use of stents in a total of 1,198 patients. The median technical and clinical success rates were 94% (i.q.r. 90-100) and 91% (i.q.r. 84-94), respectively. The clinical success when used as a bridge to surgery was 71.7%. Major complications related to stent placement included perforation (3.76%), stent migration (11.81%), and reobstruction (7.34%). Factors related to an increased complication risk were identified. Stent-related mortality was 0.58%. Limited available data suggest that this approach may be cost effective in the preoperative setting.Placement of self-expanding metal stents is an effective and safe definitive procedure in the palliation of malignant colorectal obstruction. In operable patients, it provides a useful option to avoid colostomy, by facilitating safer single-stage surgery.

This represents an overview of the main data published over the last year on the therapy of Helicobacter pylori. The problem of increasing failure of H. pylori eradication has been the main focus, with increasing resistance and poor patient compliance being the main culprits. Simple regimens are necessary to improve patient compliance. New antibiotics and novel agents are appraised with mixed results.

Hepatitis C (HCV) is a common cause of morbidity among patients who attend general practitioners (GPs) in Ireland for methadone maintenance treatment. To describe the development and content of guidelines for the management of HCV among current or former opiate users in the Eastern Regional Health Authority area attending GPs for methadone treatment. The guidelines were produced in five stages: identification of key stakeholders; development of evidence-based draft guidelines; discussion of content; determination of ‘Delphi’-facilitated consensus and review by a sample of GPs for whom the guidelines would be intended. The guidelines contain advice for GPs on all aspects of care of patients at risk of HCV, including general and preventative care, care of other bloodborne and hepatotoxic viruses, and the factors to be considered and appropriate evaluation prior to referring a patient for assessment at a hepatology unit. GPs have an important role to play in the care of patients at risk of, or Infected with, HCV.

Coeliac disease is a condition predominantly of the small bowel, resulting from sensitivity to ingested gluten, a protein found in wheat, barley and rye. Coeliac disease may be present in approximately 1 in 150–300 Europeans, yet it remains underdiagnosed in most countries. Coeliac disease as a clinical entity has been recognized for many years. As far back as the second century AD, Aretaeus from Cappadocia described what is believed to be the first report of a gastrointestinal condition resembling coeliac disease when he outlined a chronic wasting illness associated with diarrhoea. The first detailed description of the ‘coeliac affection’ was in 1888 by Samuel Gee, a paediatrician in St Bartholomew’s Hospital, London, who was also the first to propose dietary manipulation as the mainstay of treatment. However, his diets were quite restrictive, and although patients improved, few could be prevailed upon to endure the regimen for long. During World War II, food shortages, in particular of cereal, led Dicke, a Dutch paediatrician, to the conclusion that a ‘wheat factor’ led to coeliac disease. Affected children thrived when cereal was in short supply and deteriorated once the products became widely available again.

Gastric antral vascular ectasia, or 'watermelon stomach', is a rare but important cause of gastrointestinal blood loss and anaemia, which has characteristic endoscopic and histological features. The pathogenesis of this condition remains unclear; however, many associated disorders have been documented. Various medical, surgical and endoscopic therapeutic modalities have been attempted with variable success. Leading contenders for the therapeutic modality of choice include hormonal therapy, endoscopic Nd:YAG laser and argon plasma coagulation. Randomized controlled trials to identify the ideal treatment method are lacking at present.

A 'test and treat' strategy is advocated for patients with dyspepsia under the age of 45 years, with endoscopy reserved for those with alarm symptoms or aged over 45 years. One of the consequences of this strategy will be a reduction in population infection rates of Helicobacter pylori. It is now clear that H. pylori is one of the prime initiators of gastric cancer with up to 70% of gastric cancers attributable to H. pylori. What remains unclear is if H. pylori reduction will lead to a reduction in gastric cancer.

Ultimately, we now know of course that gastric urease is bacterial in origin, and our raison d’etre in the treatment of peptic ulcer is not, as Fitzgerald thought, to enharice urease activity but to completely suppress it. In the 1980s, Oliver Fitzgerald maintained a keen interest in the rapidly evolving H. pylori saga, and his wry sense of deja vu was obvious in personal contacts and correspondence the authors had with him on the subject. With the benefit of hindsight, cynics might dismiss the work of the Fitzgerald group, but their ideas on peptic ulcer are as relevant today as they were 50 years ago. We are still striving to readjust the ill-adjusted interplay between secretion, neutralisation and mucosal resistance in the dyspeptic patient. The discovery of H. pylori has simply made our task a lot easier.

The cagA 3' region shows marked variation among Helicobacter pylori strains. Two segments of 102 bp and 57 bp are reportedly responsible for this variation. We analysed the cagA 3' region in 70 H. pylori strains using polymerase chain reaction and sequencing. We found that another segment, namely beta segment, was also involved in the variation of this region. The beta segment was 105 bp long and located between the aforementioned two segments. Six genotypes were identified based on the structure of the cagA 3' region. No relationship was found between these genotypes and the clinical outcomes or vacA genotypes. The numbers of tyrosine phosphorylation sites within the cagA 3' region varied among strains, but this was not related to the cagA genotypes. Our data suggest that the cagA 3' region is significantly variable. It appears that the variation of the cagA 3' region might contribute to the modification of virulence.

Recent epidemiological studies have reported a threefold increase in the incidence of adenocarcinoma of the lower oesophagus and gastro-oesophageal junction (cardia). There are conflicting reports available implicating both gastro-oesophageal reflux disease and Helicobacter pylori infection in the aetiology of carditis and cardia intestinal metaplasia, despite strong evidence to show that these two conditions are, if anything, inversely related. We aimed to determine the prevalence of carditis and cardia intestinal metaplasia in dyspeptic subjects and also their association with H. pylori infection and gastro-oesophageal reflux disease.Histological samples from the gastric cardia were obtained from dyspeptic subjects. H. pylori status was assessed based on histological, microbiological and rapid urease testing. Gastro-oesophageal disease was diagnosed on the basis of histological evidence and/or erosive oesophagitis. Patient demographics were recorded. Cardia intestinal metaplasia (CIM), when present, was subgrouped as complete or incomplete.Overall, 276 subjects were enrolled; 163 (59%) had carditis and 36 (13%) CIM. H. pylori infection and gastro-oesophageal reflux disease occurred in 64 (23%) and 150 (54%), respectively. H. pylori infection was strongly associated with carditis and CIM (P0.001 and P0.01). Older age and male gender were also associated with inflammation and intestinal metaplasia of the cardia. Gastro-oesophageal reflux was not associated with either entity.Carditis and CIM occur frequently. Both conditions are strongly associated with H. pylori infection, older age and male gender. There was no association with gastro-oesophageal reflux disease.

Dyspepsia is a common condition, reported to affect 40% of the adult population in the developed world annually, with an estimated incidence of 8%. Dyspepsia accounts for 2% to 3% of all general practice consultations. It has been estimated that only 10% of sufferers seek medical advice, and 22% of these are referered to a specialist. Older patients are more likely to present, probably because of concern about the possibility of significant underlying pathology. Nonulcer dyspepsia (NUD) is the underlying diagnosis in a considerable proportion of individuals with dyspepsia. The prevalence is highest in young patients (younger than 25 years old), but in patients older than age 60 with dyspepsia, 20% have a normal endoscopy. NUD comprises a symptom complex referable to the upper gastrointestinal tract that persists for longer than 4 weeks, for which neither a biochemical nor structural abnormality can be identified. Diagnostic criteria were established by the Rome Consensus Committee in 1991 59 and were updated in 1998 in Vienna. The cause of NUD appears to be multifactorial, and different mechanisms may result in different subtypes of disease, which have been subgrouped on the basis of the predominant symptom type—ulcerlike, refluxlike, and dysmotilitylike. The management of NUD is varied depending on the cause and individual response to treatment. The role of Helicobacter pylori infection in the pathogenesis and treatment of NUD is an area of ongoing avid research and remains controversial. Patients with NUD are more likely to be infected than asymptomatic individuals, and there is evidence to show benefit, in at least a subset of sufferers, after eradication of H. pylori . Dyspepsia causes considerable morbidity and has substantial socioeconomic implications, as a result of workdays lost and the expense of medical investigations and treatment. The estimated total cost of dyspepsia to the United States in 1993 was greater than $14 million.

Summary Non-steroidal anti-inflammatory drugs (NSAIDs) and Helicobacter pylori are well-recognized causes of gastroduodenal mucosal damage. This damage is mediated through the effects of both agents on acid secretion, neutrophil activity and function, and prosta- glandin metabolism. Clinical trials on the interrelation- ship between H. pylori, NSAIDs and gastroduodenal mucosal injury have yielded conflicting results. No consensus has been reached on what recommenda- tions should be implemented with regard to H. pylori eradication in patients on long-term NSAID therapy. At present, the presence of H. pylori is identified at endoscopy and eradication is carried out in symptomatic patients. Asymptomatic patients remain a dilemma that requires further investigation. Clinical practice will continue to be tailored to a patient's individual requirements. Therefore, in patients at risk of gastrointestinal haemorrhage, and on NSAID therapy, acid suppression therapy should be prescribed.

Background and Study Aims: Hydatid disease of the liver, and its complications, causes serious morbidity and mortality. We evaluated the role of endoscopic retrograde cholangiopancreatography (ERCP) in the management of hepatic hydatid disease. Patients and Methods: This retrospective analysis includes 28 patients with hepatic hydatid disease who underwent ERCP. ERCP was performed preoperatively in 11 patients, for acute cholangitis (n=7), acute pancreatitis (n = 1) and right upper quadrant pain (n = 3), and in eight asymptomatic cases to search for fistulae between the cyst and the biliary tree. In a further nine patients ERCP was performed for early (< 30 days; n= 7) and late (n = 2) postoperative biliopancreatic problems. Results: In all seven patients with cholangitis preoperative ERCP with EST and ductal clearance of daughter cysts and debris led to substantial clinical improvement, including four acutely ill elderly patients who stabilized and were later able to undergo surgery. EST in two of the three patients with pain who had papillary stenosis led to resolution of the abdominal pain. Six of the seven postoperative fistulae could be successfully treated endoscopically using EST. Conclusions: This study demonstrates the usefulness of ERCP in symptomatic patients with hepatic hydatid cysts; EST enables clearance of the common bile duct and allows healing of postoperative fistulae in the majority of patients. We do not, however, recommend performing routine preoperative ERCP in asymptomatic patients with the disease.

Background: Studies in young dyspeptic patients have suggested that screening strategies based on non-invasive H. pylori testing can reduce endoscopy workload by 25–40%. Such strategies usually propose that only H. pylori-positive individuals should undergo endoscopy. This approach may fail to diagnose idiopathic ulcers, ulcers in patients whose screening test is falsely negative and reflux disease. Aim: To investigate a hypothetical screening strategy in which endoscopy is initially performed only in H. pylori-negative dyspeptics. Methods: Seventy-two consecutive patients under 45 years of age undergoing investigation for ‘ulcer-like’ dyspepsia had invasive and non-invasive determination of H. pylori status. Individuals found to be H. pylori-positive at endoscopy received 1 week of proton pump inhibitor-based triple therapy. H. pylori-negative individuals received therapy tailored to their diagnosis. Endoscopy was repeated in the positive group to confirm successful eradication. Results were analysed according to our strategy, i.e. serologically-positive patients would have received eradication therapy without endoscopy, but patients found to be negative would have been referred for endoscopy. Results: According to the serology test there were 39 positive and 33 negative results. Symptoms failed to resolve during follow-up in nine of the serological positives despite successful eradication. There were also five false positives who were deemed likely treatment failures. Thus according to our strategy, these 14 serologically-positive patients would ultimately have required an endoscopy and the other 25 serologically-positive patients would have avoided an endoscopy, resulting in a 35% reduction in endoscopy usage in this population. In the serologically-negative group there were three cases of peptic ulcer disease where the test was falsely negative, but they were detected by the strategy. No cases of gastric malignancy were detected at endoscopy. Thus our strategy would have reduced initial endoscopy referrals by 35% in this selected population. Conclusion: A strategy of empirical H. pylori eradication therapy can safely reduce the requirement for endoscopy in young dyspeptic patients without sinister symptoms.